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ALUMNI 



edical 

AUTUMN 1996 




Pride 
and 



Fellowships 



1997-1998 



Fellowships are available for a year of post-grad uafe study. The amounts 
awarded for stipends are determined by the specific needs of the 
individual. 

Moseley Traveling Fellowship 

Support for at least a year of postgraduate study in Europe. 

The Committee on Alumni/ae Fellowships gives preference to those 

Harvard Medical School graduates who have: 

1 

demonstrated their ability to make original and meritorious contributions 

to knowledge, 

2 

planned an innovative program of study which in the Committee's opinion 

will contribute significantly to their development as teachers and scholars, 

3 

clearly planned to devote themselves to careers in academic medicine 

and the medical sciences. 

Warren-WhItman-Richardson 

Support for research in the U.S. or abroad; not restricted to alumni. 
Directed to M.D. scientists who require further training. 

Deadline 

Although there is no specific due date, the Committee requests that 
applications be submitted not more than one year in advance of the 
requested beginning date. The Committee meets once a year in January 
to review all applications on file by December 31. 

Information and application forms may be obtained from: 

Committee on Alumni/ae Fellowships 

c/o Sponsored Programs Administration 

Harvard Medical School 

Room 414, Building A 

25 Shattuck Street 

Boston, Massachusetts 021 15 

617/432-1596 



Autumn 1996 
Volume 70 Number 2 



Harvard Medical 



ALUMNI 



BULLETIN 




Class Day co-moderator 
Donna Marie Manasseh '96 
and her mother. 
Photo by Lionel Delevingne 



10 CLASS DAY 

16 The Joy and Solace of Surgery 

by Joseph E. MiiiTay 
A quilt of memories. 
A Collage of Talents 

by Ellen Barlow 

20 Prepared for the Future 

by Joshua Sharfstein 

The party is over and it's time to 

get a job! 

23 On the Way Out of Harvard 

by Chih-Hwig Jason Wang 
There's nothing we can't do. 

24 ALUMNI DAY 



42 REUNION REPORTS 

51 An Alumnus Travels the New Pathway 

by Harry S. Jacob 

56 Alumna Profile 

Eve Higginbotham 

Departments 

3 Letters 

4 Pulse 

Perspective on disabihty, helper 
T cells studies, Center for Health 
and the Global Environment opens. 

7 On the Quadrangle 

Student Debt Rehef. 



27 The Unsteady State of Health Care 

by Kenneth I. Shine 

Meaningful alliances are critical to 

the outcome. 

Symposiac Moments of the Class 

of 1971 

by Sarah Jane Nelson 

32 Sacred Principles 

by Nina E. Tolkojf-Rubin 

New paradigms must remain true to 

the traditions. 



9 President's Report 

by Stephanie H. Pincus 

53 Alumni Notes 

58 In Memoriam 

Melvin P. Osborne 
Robert Higgins Ebert 
A. Clifford Barger 

63 Death Notices 



35 Protecting Our Empathy 

by Joshua M. Hauser 

The difficulty of maintaining values 

learned in medical school. 



39 The Ethics of Efficiency 

by James E. Sabin 

In pursuit of good practice in 

managed-care psychiatry. 



Inside hmab 



Harvard Medical 



A L u M N 



BULLET 



The Class of 1996 has graduated, the Class of 2000 has matriculated. 
Is the millenium ending or approaching? For four or five millenia 
there have been physicians. Ancient Egypt and Mesopotamia had 
social roles corresponding, more or less, to the modern M.D., and 
the identity has persisted, with fluctuating fortunes, ever since. 

In a way, this is a remarkable fact; for a truly effective technology 
of medicine has emerged only within the last century. (Some surgical 
procedures have a longer history, as do odds and ends of other thera- 
pies. Bloodletting, the cornerstone of most medical practice for at 
least 3,000 years, had a few defensible uses but nowhere near enough 
to justify the extent of its application throughout Western medicine 
until roughly my great-grandfather's time.) In other words, the con- 
cept of a doctor who uses physical means to cure or ameliorate illness 
has persisted as if the materia medica were effective, for about 98 per- 
cent of the recorded history of medicine, and it is only in the last 
blink of time that the reality has come to correspond with the image. 

Perhaps the reason doctors have had for being was precisely that 
the treatments weren't very good. And now, as my friend and col- 
league Jay Bonnar '91 recently pointed out to me, we so often know 
what is effective, and we are under enormous fiscal pressure to pro- 
vide it efficiently. The end result, he suggests, may well be the steady 
dismemberment of the physician's identity (and therefore training) 
into a variety of lower-priced technical specialties. What need is 
there for an antidepressant technician to deliver a baby during his or 
her training? Or a rash technician to have a conversation with a psy- 
chotic patient? Why even have doctors as such — except perhaps to 
open gates and close them efficiently? 

Even as we rejoice in the latest generation of hugely gifted, 
trained, and debt-burdened Harvard physicians, I think we must ask 
such questions; for all the economic pressures will drive us not only 
to accept lower pay and degraded working conditions but to relin- 
quish our age-old identity. Then, quite possibly, no one will be left to 
fight our good fight. 

As of this issue of HMAB, however, the happy warriors abound. 
Their reflections from the most recent Class and Alumni Days 
follow. 

William Ira Bennett ^68 



Editor-in-chief 

William Ira Bennett '68 

Editor 

Ellen Barlow 

Associate Editor 

Janet Walzer 

Assistant Editor 

Sarah Jane Nelson 

Editorial Board 

Elissa A. Ely '88 
Melinda Fan '96 
Robert M. Goldwyn '56 
Joshua Hauser '95 
Paula A. Johnson '84 
Victoria McEvoy '75 
James J. O'Connell '82 
Gabriel Otterman '91 
Deborah Prothrow-Stith '79 
Guillermo C. Sanchez '49 
J. Gordon Scannell '40 
Eleanor Shore '55 
John D. Stoeckle '47 
Richard J. Wolfe 

Design Direction 

Sametz Blackstone Associates, Inc. 

Association Officers 

Suzanne Fletcher '66, president 
Robert S. Lawrence '64, president-elect i 
George E. Thibault '69, president-elect 2 
Roman W. DeSanctis '55, vice president 
David D. Cakes '68, secretary 
Arthur R. Kravitz '54, treasurer 

Councillors 

David P. Gilmour '66 
Laurie R. Green '76 
Katherine L. Griem '82 
Gerald T. Keursch '62 
Dana Leifer '85 
Alison G. May '91 
Sharon B. Murphy '69 
Gilbert S. Omenn '65 
John B. Stanbury '39 

Director of Alumni Relations 

Daniel D. Federman '53 

Representative to the Harvard Alumni Association 

Chester d'Autremont '44 

ID Statement: 

The Harvard Medical Ahmmi Bulletin is published 
quarterly at 25 Shattuck Street, Boston, MA 02 1 15 
© by the Harvard Medical Alumni Association. 
Telephone: (617) 432-1548. Email address: 
bulletin@warren.med.harvard.edu. Third class postage 
paid at Boston, Massachusetts. Postmaster, send form 
3579 to 25 Shattuck Street, Boston, MA 02 11 5, 
ISSN 0191-7757. Printed in the U.S.A. 



Harvard Medical Alumni Bulletin 



Letters 



Faith Factor 

In Herbert Benson's interesting and 
provocative article, "Wired for God," 
(Summer 1 996) he notes that faith 
seems to transcend experience. 
Sometimes, however, experience 
almost transcends and certainly rein- 
forces faith. 

Let me illustrate. In 1952, after 
spending a year in Paris studying trop- 
ical medicine, and shortly after arriv- 
ing in interior Cote d'lvoire, West 
Africa, hundreds of miles from signifi- 
cant medical care, I found myself con- 
fronted with a small boy shot in the 
mid-abdomen in a hunting accident. 
The wound was by a dum-dum, 
expanding 22 bullet. With two 
American missionary nurses, I had 
spent most of the day unpacking my 
equipment and sterilizing an obstetric 
and surgical pack in a pressure cooker 
for an anticipated delivery. 

There was no other choice — send 
the child away or operate and try to 
save his life. It was truly kitchen-table 
surgery. One nurse dropped ether 
onto the mask according to my 
instructions as we went along, while 
the other assisted me. My wife held 
the flashlight and wielded a fly swatter. 

Upon opening the abdomen I 
found the small bowel shattered in one 
location and multiply perforated else- 
where. My heart sank. I had had some 
surgical training but was by no means 
an accomplished surgeon. By the time 
I had finished a resection and reanasta- 
mosis, the child's blood pressure was 
rapidly dropping and the pulse 
increasing. Therefore, I closed eight 
other perforations with a single stitch 
each and rapidly closed the abdomen. 
We had no IV fluids. Postoperatively, I 
set up a siphon-type gastric suction, 
but it failed to function. Nevertheless, 
during the night the little patient 
seemed to stabilize. 



The next morning I listened to his 
abdomen and was amazed to hear nor- 
mal bowel sounds. But he was severely 
anemic. We needed blood, yet the 
only person who cross-matched prop- 
erly was the one who shot the boy. I 
could have obtained four liters from 
him, but needed only one unit. The 
child recovered rapidly. The news 
spread that I had performed a miracle. 
Actually, all I had done was to do 
exactly what I had learned in dog 
surgery. Even so, I believe that I had 
witnessed a miracle. 

During the next several years in 
Africa, that experience in various 
forms was often repeated, each inci- 
dent strengthening my faith for the 
almost overwhelming task of providing 
health care and seeking to reflect 
God's love in a neglected part of a 
French colony. 

Charles B. Beat '^6 



Who Dunnit? 

As a student (Class of '52) who often 
sat in the Ether Dome tiers at the 
Mass. General, and later was chief sur- 
gical resident (1953-57) at Roosevelt 
(NY City) where Hall, Kelly, Halstead 
and McBurney operated and taught, I 
cannot let Dr. S.H. Moore's article 
"Who Did the First Appendectomy?" 
(Summer 1996) go unchallenged. 

Just who was Alfred Worcester and 
why is it important to note his surgical 
exploit? 

I have just reviewed my library 
sources with respect to the historical 
nature of appendectomy and note this 
review: 

In 195 1 John Burke of the 
Department of Surgery at the 
University of Buffalo School of 
Medicine published an article entitled 
"Early Aspects of Appendicitis." This 
was a 1 2 -page review with 59 refer- 
ences {Surgery, volume 30, number 5, 
pages 905-917) and nowhere is there 
mention of the name Alfred 
Worcester. This surgical review article 
was only 18 years after Dr. Moore's 
related visit with Dr. Worcester. 

In 1963 there was an editorial in 
JAMA (volume 185, number 3, July 20, 
1963, pages 140-41) regarding Dr. 
Reginald Heber Fitz commenting 
upon Fitz's contribution to appendici- 
tis/appendectomy management. There 
is no reference to Worcester. 

In 1966 there was an editorial in 
JAMA (volume 197, number 13, 
September 26, 1966, pages 1098-99) 
regarding Dr. Charles McBurney. 
Although the editorial was not about 
verifying the originator of appendec- 
tomy, there is no hint of Worcester in 
the acknowledging of Fitz's report of 
1886 to the Association of American 
Physicians and McBurney's report of 
1889. 

In 1985 Dr. Daniel H. Carmichael 
of Oklahoma City reviewed Fitz's con- 



AUTUMN 1996 



Letters 



Pulse 



tributdons to the management of 
appendicitis ("Reginald Fitz and 
Appendicitis," Sonthetii Medical 
Journal, volume 78, number 6, June 
1985, pages 725-730). This article 
quotes numerous famous and leading 
surgeons of the late 1800s, e.g., 
Howard A. Kelly, Charles McBurney, 
Will Mayo; and of the early 1900s: 
Dean E.H. Bradford of Harvard 
Medical School, W.H. McKean, pro- 
fessor of surgery at Jefferson Medical 
School, and W.S. Thayer at Johns 
Hopkins, to name some. These med- 
ical leaders nowhere acknowledge 
Alfred Worcester as performing the 
first appendectomy in New England. 
Indeed, Worcester, as a pupil of 
Reginald Fitz, is mentioned at the end 
of this article only in terms of praising 
his teacher. 

Finally (and most recently, from 
my own references) J. Lynwood 
Herrington Jr., professor of surgery at 
Vanderbilt, published a very thorough 
review, "The Vermiform Appendix: Its 
Surgical History" (Contemporary 
Surgery, volume 39, October 1991, 
pages 36-44), which was 8 pages long 
and had 77 references. Interestingly, 
there is no reference to or mention of 
Alfred Worcester performing the first 
of anything. 

From this investigation of the liter- 
ature, I have arrived at three conclu- 
sions: 

• As Harvard has gotten into the 
multicultural and political correctness 
business in the last few years, I wonder 
if Dr. Moore's point is endeavoring 
somehow to get Harvard into the 
"appendicitis/appendectomy" story 
more than it is already. 

• Is it important or necessary to rec- 
ognize that a Harvard surgeon per- 
formed the first appendectomy in New 
England in 1886? I am surprised there 
is no reference to the first black sur- 
geon to perform an appendectomy (in 



the U.S.) or the first German immi- 
grant surgeon who did the first appen- 
dectomy in Wisconsin, ad. inf., etc., ad 
nauseam. 

• If Dr. Moore's article is to tweak 
historical curiosity, he has tweaked! 

I am now searching for evidence of 
the surgeon (hopefully a Harvardian) 
who performed the first appendectomy 
in North Carolina! 

Wesley Grimes Byerly '52 

Moore replies 

I agree completely with Dr. Byerly 
that there is no point in promoting the 
idea that Dr. Alfi-ed Worcester made a 
name for himself by being the first 
New England surgeon to do an appen- 
dectomy, or that Harvard graduates 
should be given any accolades as the 
first to do this operation. My purpose 
in presenting the brief account was to 
let the reader join me in my search for 
an answer to Donald Gates' comment 
in 1933 that he knew the doctor who 
performed the first appendectomy, 
namely, Alfred Worcester. 

I thank Dr. Byerly for his letter 
because it focuses more attention on 
Alfred Worcester, whose vigorous 
campaign to persuade his fellow physi- 
cians to be aggressive and operate 
early to save lives was really impres- 
sive. When he came to Harvard to be 
in charge of the student health pro- 
gram, the nunor that he had done the 
first appendectomy soon spread all 
over the Yard. My aim was to separate 
the myths from the truths. 

I now can see another advantage of 
my article. When anyone asks Dr. 
Byerly if he knows anything about Dr. 
Worcester, he can impress that person 
by promptly saying, "Oh yes. You see, 
I read the Harvard Medical Alumni 
Bulletin.'" 

S. Halcuit Moore, Jr. 'jj 



The Perspective of Disability 

Where there are many myths and mis- 
conceptions about people with disabil- 
ities, a relatively new HMS program has 
set out to confront them head on. Joel 
Stein, director of the inpatient physical 
medicine and rehabilitation service at 
Spaulding Rehabifitation Hospital, 
organized the program to bring med- 
ical students face-to-face with current 
and former Spaulding patients. More 
than 100 HMS students participated in 
the 19-session program, which has 
been offered the past three years to all 
first-year students at the end of 
Patient-Doctor I. 

Judy Gilbert, one of this year's vol- 
unteers, began her session by explain- 
ing some of the barriers she faces. She 
had a stroke 2 2 years ago and has since 
then relied on a wheelchair; only her 
right arm is unimpaired. "Some people 
have not taken the time to wonder 
what it's like to live with a disabihty," 
she told the students. "It is critically 
important that you see a disabled per- 
son as a whole person, one who relates 
to friends and family, as a functioning 
human being, not someone who is ill." 

Other volunteers in the program 
have equally limiting disabilities, such 
as caused by stroke, spinal cord injury, 
multiple sclerosis and cerebral palsy. 

Stein pointed out three common 
myths about disabled patients: 

• Everybody with a disability is the 
same. 

• People with disabilities always want 
help. 

• People with disabilities never want 
help. 

Though everybody with a disability 
is not the same. Stein did say there are 
common challenges they face, such as 
fastening buttons or tying shoelaces. 
Doctors may be involved in such prob- 
lems as transferring a patient from a 
wheelchair to an exam table or in 
working around a patient's involuntary 



Harvard Medical Alumni Bulletin 



movements during a physical examina- 
tion. He also pointed out that it can- 
not be assumed that sexuality goes 
away along with use of the limbs. 

It is important for medical students, 
says Stein, "to gain knowledge about 
living with disabilities, thereby devel- 
oping a capacity to ask questions 
showing sensitivity and awareness." 



Helper Cells to the Rescue 

Researchers have realized that the 
body's arsenal to fight invading 
pathogens is much more extensive 
than they had thought only 20 years 
ago. When a foreign antigen enters 
the body, the immune system does not 
simply mount a generic "immune 
response," but instead, carefully 
assembles for dispatch a specialized 
army of defense cells. Two Harvard 
research groups recently discovered 
the identity and function of genes that 
direct the recruitment and differentia- 
tion of a T helper-cell army during an 
immune response. 

Nine years ago researchers discov- 
ered that the body has two distinct 
types of T helper cells, which differ by 
the type of physiological defense 
mechanisms they rally to carry out 
battle with a pathogen. When it 
turned out a few years later that the 
balance between these two T helper 



cells was intimately linked to disease, 
the search began to uncover the mole- 
cular basis of this differentiation. 
Recendy, separate research groups led 
respectively by Laurie Glimcher '76 
and Michael Grusby have filled in 
three major pieces of the puzzle. 

Glimcher, Irene Heinz Given 
Professor of Immunology at the 
Harvard School of Public Health and 
professor of medicine at Harvard 
Medical School, reported in the June 
28 Cell that a transcription factor 
called c-maf is expressed only in T 
helper 2 cells, and that it probably dri- 
ves additional undifferentiated T cells 
to mature specifically into T helper 2 
cells. It effectively helps to recruit a 
Th 2 army. 

Concurrently, Grusby, assistant 
professor at the Harvard School of 
Pubhc Health and at Harvard Medical 
School, shed light on another segment 
in the molecular chain of events 



Michael Grusby and 
Laurie Glimcher 




Autumn 1996 



Pulse 



leading to differentiation. He and his 
colleagues reported in the July 1 1 
Nature that a member of the STAT 
family of signaling proteins, Stat4, 
turns out to be a "master switch" in 
the development of T helper i cells. 
This paper was on the heels of 
Grusby's report in the March 
Immunity showing that Stat6 switches 
on the development. 

When the immune system needs 
T helper cells to combat a pathogen, 
it does so by instructing T cells, which 
have not yet encountered a foreign 
antigen, to mature into either T helper i 
or T helper 2 cells. 

These specialized T cell subsets 
normally arise in just the right balance 
to orchestrate an attack against the 
invader. But the system is out of kilter 
in several immune-system disorders. 
The swollen joints in rheumatoid 
arthritis, for example, contain too 
many Th i cells, as do organs under 
assault by the body's defense system in 
other autoimmune diseases. 

Conversely, Th 2 cells greatly out- 
number Th I cells in certain infectious 
diseases and tumors. 

Consequentiy, researchers have set 
their sights on trying to tip the T 
helper-cell balance as a way to treat 
immune disorders much more specifi- 
cally than the current, generalized 
immunosuppressants. 

"Almost every disease that is medi- 
ated by the cellular arm of the immune 
system is in some aspects controlled by 
T helper-cell subsets," says Grusby. 

That is why the idea of manipulat- 
ing the balance of Th i and Th 2 cells 
holds such general appeal as a poten- 
tial new approach to treatment. 



Eric Chivian 



Center for Health and the Global 
Environment Opens 

At a Harvard-MIT symposium four 
years ago, a group of HMS physicians 
who had helped form Physicians for 
Social Responsibility (which was the 
co-recipient of the 1985 Nobel Prize) 
to address the issue of nuclear war 
three decades earlier, began a new 
campaign. Their goal was to educate 
the public on the effects of the global 
environment on human health, a mis- 
sion that has been formalized with the 
opening of the Center for Health and 
the Global Environment on June 1 7 at 
HMS. It is the first center of its kind at 
a U.S. medical school. 

Under the leadership of Eric 
Chivian '68, HMS assistant clinical pro- 
fessor of psychiatry, the center will be 
involved in a variety of activities to 
make people aware of how they will be 
affected by the changing environment. 

"Despite all of the scientific infor- 
mation about global climate change 
and species loss and the ozone layer, 
people still see themselves as separate 
from the environment," comments 
Chivian. "They find the implications 
too frightening, too abstract, too hard 
to imagine." Yet there is now an 
increased risk for skin cancer due to 
the weakened ozone layer, and infec- 
tious diseases are on the rise from 
global warming and changing weather 
patterns. 

Chivian and his staff hope to 
increase people's awareness through 
public education and coordination of 
national and international research 
efforts, in addition to working directiy 
with policymakers. The center will 
also develop a student course on 
human health and the global environ- 
ment, another first for a U.S. medical 
school. The curriculum will cover a 
broad spectrum — from the conse- 
quences of species extinction and pol- 
lution of ecosystems, to the ethical and 




«> 




policy implications of the degrading 
global environment. 

"We think medical students really 
need to know about these issues and 
that future physicians need to be 
involved in educating the public and 
policymakers," adds Chivian. It will be 
open to both HMS and Harvard 
University students and is expected to 
become a model for other medical 
schools and universities. 

Along with these educational 
efforts, the center will develop a 
research agenda for the next decade on 
the areas of the changing environment 
that pose the most risk to human life. 
This information will then be pre- 
sented to the United Nations and the 
administration in Washington. In 
addition, through a site on the World 
Wide Web, the center will act as a 
clearinghouse for research and post a 
monthly newsletter. 

"What we most want to accomplish 
is to place human health at the center 
of the global environmental debate. If 
people begin to understand the risks to 
themselves and their children, they 
will be motivated to protect the 
world's environment," says Chivian. 



Harvard Medical Alumni Bulletin 



On the Quad 



student Debt Relief 

Driven by a charge from Dean 
Federman and fueled by a simultane- 
ous lobby effort from HMS students, 
the Financial Aid Committee is bring- 
ing a surge of energy to tackling stu- 
dent indebtedness. Although the 
problem has been a priority since 1991 
when an earlier task force was con- 
vened by Dean Tosteson to study the 
issue, "a confluence of factors," says 
Robert Dluhy '62, chair of the 
Financial Aid Committee, has moved 
the committee to go beyond present 
policies and "create a new initiative." 
These factors include a rapidly chang- 
ing medical environment and a drop in 
physician earnings. "But mostly," 
notes Dluhy, "it is the difficulty stu- 
dents are having with this issue, both 
emotionally and financially." 

In the spring of 1995 the Financial 
Aid Committee convened a long-term 
planning subcommittee to address the 
widening gap between the student 
financial aid budget and the cost of 
attending HMS, and between student 
indebtedness and declining physician 
salaries. They felt it was necessary to 



form this subcommittee, explains 
Theresa Orr, assistant dean and direc- 
tor for admissions and financial aid, 
because "It became more and more 
difficult to ration already rationed 
resources," making it necessary to 
"contribute to a long-range plan for 
increasing resources." 

As the committee was putting 
together information for what has now 
become the "Financial Aid Committee 
Proposal for Student Debt Relief," a 
group of students from the Class of '98 
was doing their own research. A ques- 
tionnaire was developed to collect data 
on student attitudes about debt, which 
was administered to classes 1997 and 
1998. Each class had an impressive 70 
percent return rate. 

The findings of this data collection 
were summarized in a December 1995 
report entitled "Student Initiative for 
Financial Aid Reform." Sixty-nine per- 
cent of the respondents in the two 
classes reported that they anticipated a 
debt greater than $80,000. In the Class 
of 1997, 60 percent reported borrow- 
ing the total unit loan while 28 percent 
reported borrowing beyond the full 



unit loan. For the Class of 1998, the 
statistics were similar, with 58 percent 
borrowing the total unit loan and 36 
percent borrowing beyond the full unit 
loan. The unit loan is the amount a 
student must borrow before being eli- 
gible for scholarship money. Thus, a 
student's financial need must be 
greater than the total unit loan amount 
in order to be eligible for scholarship 
funds. Of the four reform proposals 
offered to students in the survey, over 
60 percent voted the reduction of the 
unit loan as their first choice. 

Not surprisingly, the committee 
found the students' concerns com- 
pelling and proposed reducing the unit 
loan at the Faculty Council meeting in 
April. With the active support of Dean 
Tosteson, the proposal was approved 
by the council. Beginning with this 
year's incoming class through the year 
2000, the unit loan will drop from 
$25,000 to $20,000. 

Close to $1 million in additional 
scholarship availability is necessary per 
year for the next four years to make up 
the difference. To address this immi- 
nent need, the Harvard Corporation 



Year 



1995 



Median Pliysician 


Median Pliysician 


Boston C.P.I. 


Average Student 


Percent of Average 


Compensation 


Compensation 
Change from 
Previous Year 


Increase 


Indebtedness 


Indebtedness to 
Median Physician 
Compensation 



1989 


131,526 


— 


— 


46,721 


35.52% 


1990 


139,264 


5.9% 


6.1% 


47>357 


34.01% 


1991 


146,213 


5.0% 


6.9% 


54,800 


37.48% 


1992 


155-925 


6.6% 


4.0% 


5i>438 


32.99% 


1993 


159,564 


2.3% 


4.4% 


5i>774 


32.45% 


1994 


163,062 


2.2% 


1.7% 


58,288 


35-75% 



'150,000 (est.) 



-8.0% (est.) 



2. 2% (est.) 



66,231 



44.15% 



Source for 1989 through 1994 Physician Median Compensation: M.G.M.A. Physician Compensation and Production 
Survey: 1995 Report based on 1994 data 

• A.M.A. indicates that the projected median physician compensation for /5>^4 would approximate $150,000; whereas 
Medical Group Mmiagement Association indicates that 1994 was $163,062. Further, M.G.M.A. provided information that the 
projected 199^ physician would approximate $1^0,000. 

Data for this table prepared by F. Katz, Katz, Baltimore & Co. P.C. 



Autumn 1996 



On the Quad 



recently approved Dean Tosteson's 
proposal to decapitalize endowed 
funds to provide an immediate 
increase of scholarship resources. In 
addition, a close to $10 million gift 
designated for scholarship by James 
Stillman '32 will help with the reduc- 
tion. 

Like the students, the committee 
offered its own sobering numbers and 
statistics to document the severity of 
the problem. For example, the number 
of students who have graduated with 
over $80,000 in debt has jumped from 
5 in 1989 to 43 in 1995. Meanwhile, 
physician salaries have declined for the 
first time in 14 years. Dluhy, an HMS 
associate professor, notes that the 
committee owes a "solid debt of grati- 
tude" to Frederic Katz, CPA, who con- 
tributed his time pro bono to 
documenting declining MD income 
and its relationship to loan payments 
(see table on page 7). 

"Fred Katz showed us that we can't 
ignore the warning signals. Launching 
students into a debt situation with 
dropping physician salaries will not be 
manageable," adds Dluhy. 

Coupled with the restructuring of 
health care (read managed care), it can 
no longer be assumed that students 
will be able to repay their loans. And a 
statistic from the committee's proposal 
brings the point home: "a typical first- 
year resident owing $100,000 in stu- 
dent loans would have to allocate 58 
percent of his/her monthly net (after- 
tax) income for loan payments, leaving 
only 42 percent ($937.00) for living 
and other consumer expenses." Not to 
mention the additional $54,900 (under 
the standard lo-year repayment plan, 
with 8.25 percent annual interest) that 
could accrue if they delay their pay- 
ments. 

The impact of this increasing debt 
on the rest of a graduate's life goes 
beyond dollars and cents. The student 



survey revealed that there was a small 
but significant correlation with how 
debt influenced choice of specialty and 
career path. And anecdotal comments 
from HMS graduates reveal that they 
postpone other things in their lives 
due to debt, such as buying a house or 
having children. 

Beyond reducing indebtedness, the 
committee is working on a number of 
remaining issues and is considering the 
following long-term strategies: 

• Establishing an approach that 
would enable students to refinance all 
their debt into one credit package to 
simplify debt management and loan 
repayment. 

• Revising repayment terms for HMS 
loan programs by extending the repay- 
ment term from 10 to 20 years and 
eliminating accrual of interest during 
residency. 

• Creating a low-income loan repay- 
ment plan for students who choose 
public service jobs with lower salaries, 
akin to the Harvard Law Schools's 
Low Income Protection Plan. 

In addition to these strategies, it is 
hoped that money will be raised for 
student financial aid through the HMS 
campaign "The need to control the 
costs of medical education is a very 
active concern of the school's adminis- 
tration at this time," points out Dean 
Federman. "We are examining every 
possible strategy toward that goal. 
Nevertheless, fundraising is a crucial 
element in the support of medical edu- 
cation. We are lucky to have in Cush 
Robinson [the dean for resource devel- 
opment and public affairs] someone 
who is personally and enthusiastically 
committed to this goal." 

An additional spark of energy for 
the debt proposal, says Dluhy, came 
from former chair of the Alumni Fund, 
A. Clifford Barger '43. He joined the 
committee as an observer, and shortly 
before his death, gave the proposal his 



blessing in a handwritten note to 
Dluhy: "If you can sell this to the 
Administration, the students will carry 
you on their shoulders around Tugo 
Circle, and I shall be there cheering 
them on." 

Often, Orr hears students com- 
ment, "I don't think Harvard would 
give me a loan unless I could repay it." 
"Before now," Orr notes, "the 
Financial Aid Committee looked at a 
snapshot of the issue, but it is no 
longer ethical to be that shortsighted. 
The crisis for students is in the future, 
but for us, the crisis is now. We must 
see the economics of the future as our 
challenge for today." 

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Harvard Medical Alumni Bulletin 



President's Report 



by Stephanie H. Pincus 



The last meeting of the Alumni 
Coimcil of the academic year was held 
on Wednesday, June 5, 1996. The 
most important issue discussed 
tmdoubtedly was the selection of the 
new dean of Harvard Medical School. 
Dean Daniel Tosteson '49 has been an 
effective leader whose major accom- 
plishments have included substantially 
increasing the endowment of the med- 
ical school and implementing the New 
Pathway curriculum. 

The Alumni Council reviewed in 
depth the challenges facing the new 
dean and the qualities that would be 
desirable. We all agreed that the next 
dean should have a good understand- 
ing of human biology in its broadest 
sense. There was considerable debate 
concerning whether the dean should 
be a "bench" scientist in the past tradi- 
tion or should have expertise in newer 
areas, such as health policy or man- 
aged care. The critical challenges of 
providing quality education under 
increasing fiscal constraints will 
undoubtedly make the deanship a diffi- 
cult and demanding position. Hence, 
an energetic leader who enjoys man- 
agement will be necessary. We have 
commimicated these ideas in writing 
to the president of the university and 
urge all alumni who are concerned to 
communicate directiy to Neil 
Rudenstine, c/o Marc Goodheart, 
Special Assistant to the President, 
Massachusetts Hall, Harvard 
University, Cambridge, MA 02138. 

Alumni Day on Friday, June 7 
focused on ethics and professionalism 
under managed care. Dean Dan 
Federman '53 organized the marvelous 
symposium which is included in this 
issue. One of the most remarkable 
events of Alumni Day was unrelated to 
the topics. Women have finally 
reached their prominence in our orga- 
nization, as illustrated by me as your 
outgoing president, your incoming 



president, Suzanne Fletcher '66, and 
the secretary, Nancy Rigotti '78, who 
were the main alumni representatives 
sitting on the stage. 

This is my final column and I 
would like to thank all of you for the 
opportunity to serve as the president 
of the Harvard Medical Alumni 
Council. I have truly enjoyed and ben- 
efited from this experience and per- 
sonally urge each of you to pitch in, 
return to the fold, and continue your 
alliance with Harvard Medical School. 

Stephanie H. Pincus '68 is professor and 
chair of the Department of Dermatology 
at SUNY Buffalo. 




Autumn 1996 




I 



■^m 




Class Day 



With the masters of the societies 
and the deans of the Faculty of 
Medicine leading the way, the Class of 
1996 proceeded down the stairs of 
Building A for the last time as stu- 
dents. They were about to receive the 
honor they had worked so hard for — 
the privilege of adding MD after their 
names. 

The waves from family and friends 
subsided and the students settled into 
the front rows of the tent. Co-modera- 
tor Donna-Marie Manasseh '96 encap- 
sulated the pride all were feeling, 
citing the support they had received 
from family, friends and teachers and 
their excitement about what the future 
holds. Jeffrey Schnipper '96, the other 
co-moderator, then tried to answer the 
question most had been asked that day: 
What does it feel like to be graduat- 
ing? "I have a range of emotions, such 
as, am I relaxing enough, do I keep or 
throw out my camels? I guess I really 
am in denial." 

Joshua Sharfstein '96, who had just 
returned from Guatemala, was roundly 
applauded when he suggested that the 
class form a small country and apply to 
the World Bank for debt relief. After 
reading an imaginary headline from 
the Wall Street Journal — "Citing 
Budget Crunch, U.S. Hospitals 
Eliminate Residency Programs" — he 
used humor to comfort his classmates 
with the marketable skills they had 
learned at Harvard Medical School. 
Skills such as how to make lists or 
memorize thousands of bits of infor- 
mation "will no doubt serve us well in 
a wide range of careers, to name just a 
few. . . telephone operator, tax lawyer 
and traveling salesman." 

Chih-Hung Jason Wang '96 
humbly depicted the achievements of 
his classmates and admitted he was 
probably the only one who had not 
been to Guatemala that year. He also 
took a crack at speculating where they 
would go from here. "I want to urge 
you, my friends, that the imbending 
spirits that brought us to Harvard 
should not stop here. Together, we 
will be the architects of the future of 



Autumn 1996 



health care and more. ^-N^e -will con- 
tinue to pass on the tradition of excel- 
lence, dedication and creativity." 

Guest speaker Joseph E. Murray 
'43B was then introduced as a pioneer 
surgeon, researcher, mentor and 
philosopher. Murray, co-recipient of 
the 1990 Nobel Prize in Physiology or 
Aledicine for his role in kidney trans- 
plantation, is professor emeritus of 
surgery at HAlS, and for 34 years was 
chief of the Division of Plastic and 
Reconstructive Surgery at both 
Children's and the Brigham and 
Women's hospitals. 

He weaved his "quilt of memories" 
from his days as a sm"geon and 
expressed his concerns about the 
destruction of hfe at both the begin- 
ning and end of life. "The medical 
profession is the ultimate bulwark for 
society against any culture of death. . . . 
As physicians we can carry the candles 
of light by ministering to our patients 
and families, by teaching and learning 
along with our students, and by inves- 
tigating the mysteries of nature." 

The co-moderators honored faculty 
and friends of the Class of 1996. The 
teaching award for the preclinical 
years went to Steven E. Weinberger 
'73, associate professor of medicine, 
and for the clinical years to Martin A. 
Samuels, professor of neurology. A 
special award for "helping arrange 
international experiences and medical 
Spanish programs" was presented to 
Guillermo Herrera. The class also rec- 
ognized the five masters of the soci- 
eties (Ronald Arky, Daniel 
Goodenough, Michael Rosenblatt '73, 
Stephen Krane and Marian Neutra), 
the society program administrators 
(Chris Coughlin, Janet Lipponen, 
Patricia Cunningham, Elaine Glebus 
and Calvin Heimig), the student affairs 
coordinator, Carla Fujimoto, and asso- 
ciate dean for student affairs, Edward 
Hundert '84. 

"Now to everyone's favorite part of 
the ceremony, the conferral of 
degrees," announced co-moderator 
Schnipper. The crowd whooped as the 
first group of graduates stood to be 



"robed" by the masters and then 
stepped across the dais for their 
degrees. Many came with their babies 
or children, who each received a teddy 
bear. There were so many offspring 
that the supply of bears ran out, 
prompting a quip from Dean Daniel 
Federman '53: "We underestimated 
your fertility; the curriculum must not 
be rigorous enough." 

Dean Daniel Tosteson '49 began 
his valediction by having the class 
stand and applaud their families. He 
told them that clearly there was no 
way they could have mastered all that 
would be pertinent to their future 
work as physicians, but that they had 
begun to build a conceptual frame- 
work to learn new knowledge as it 
becomes available. "Your pathway of 
learning begins but not ends at HMS." 

With the reading of the oath and 
one final cheer, the new Harvard doc- 
tors of the world were primed for the 
next stage of their careers. 

Among the degree recipients were 
many who graduated with honors or 
special awards. They are: 

Monica Subramanya Bettadapur, 
cum laude 

An Investigation of Revascularization 
Within Prefabricated Free Flaps 

Kingsley Richard Ciiin, cum laude 

Investigating the Interaction Between 
Parathyroid Hormone and the Human 
Parathyroid Hormone-Related 
Protein Receptor 

Timothy Lloyd Davis, cum laude 

White Matter Tract Visuahzation By 
Diffusion Tensor MRI 

Michael C. Dyce, cum laude 

The Relationship Between Endothelial 
Vasodilator Function and LDL Particle 
Size, Density, and Number in Human 
Coronary Atherosclerosis 



Anthony Carlyle Forster, magna cum laude 

A Novel Method for Ligand and Drug 
Discovery 

Jan 0. Friedrich, magna cum laude 

The Creatine Kinase System in Failing 
Myocardium: 31P NMR Magnetization 
Transfer and Spectroscopic Imaging 
Studies 

Keri Kathleen Gardner, cum laude 

Structural and Signaling Interactions 
Between the Platelet Cytoskeleton and 
Surface Receptors 



12 



Harvard Medical Alumni Bulletin 



Thomas Andrew Gaziano, cum laude 

Light to Moderate Alcohol 
Consumption and Total Mortality in 
the Physician's Health Study 
Enrollment Cohort 

Christopher M. Haqq, cum laude 

Identification of MARE- 1, a Mullerian 
Inhibiting Substance Activating 
Response Element 



Vincent Trien-Vinh Ho, magna cum laude 

Harold Lamport Biomedical Research 
Prize for the best paper reporting 
original research in the biomedical sci- 
ences: Regulation and Expression of 
the Human Erj^ropoietin Gene 

Choll Wan Kim, cum laude 

The Syndecan Family of Matrix and 
Growth Factor Co-Receptors Is 
Expressed Selectively in Mouse 
Tissue, Cultured Cells, and During 
Wound Repair 



Laura Ann Lambert, cum laude 

Irreversible Conduction Block in 
Isolated Frog Sciatic Nerve by High 
Concentrations of Local Anesthetics 

Patrick Joseph Ledden, cum laude 

Physiological Measurement with a 
Radio Frequency Loop: A Novel 
Biologic Sensor 

Laura Mauri, magna cum laude 

An Analysis of Tissue Plasminogen 
Activator Binding to Annexin II, Its 
Endothelial Cell Receptor 




The helpful hands behind Jeffrey Schnipper 



Autumn 1996 



13 




Jennifer Hirsch and her 
daughter "ceH"-ebrate 
commencement. 



Margaret Elise McLaughlin, magna cum 
laude 

Henry Asbury Christian Award for 
notable scholarship in studies or 
research: Mutations in the Gene 
Encoding the Beta Subunit of Rod 
cGMP Phosphodiesterase in Patients 
With Autosomal Recessive Retinitis 
Pigmentosa 

David Josepli Milan, cum laude 

The Molecular Mechanism of 
Immunosuppression by Cyclosporin A 
and FK506 

Jeff Allen Odiet, magna cum laude 

Influence of Age and Inhibition on 
Cardiac Carnitine Palmitoyl 
Transferase-I 



Emily Oken, cum laude 

Immunoneuroendocrine Response to 
Tetanus Toxoid. Bemyjelin '91 Prize 
to that senior who most demonstrates 
overall academic excellence with a 
career interest in pediatrics, oncology, 
international health, or psychiatry 

Arun J. Ramappa, cum laude 

A Novel Implant for Articular 
Cartilage Regeneration 

Manish Arvind Shah, magna cum laude 

The Function of Neuron Specific 
Kinesin Heavy Chain as Assessed by 
Antisense Technology 

Wendy Jennifer Spangler, cum laude 

Dr. Sirgay Sanger Award for excel- 
lence and accomplishment in research, 
clinical investigation or scholarship in 
psychiatry: Stereotactic Cingulotomy 
for Intractable Psychiatric Disease 



Kimberly Stegmaier, magna cum laude 

Leon Reznick Memorial Prize for 
excellence and accomplishment in 
research: Involvement of the TEL Gene 
in Acute Lymphoblastic Leukemia of 
Childhood 

Erich Christian Strauss, magna cum laude 

Molecular Mechanisms Controlling 
GATA-i Gene Expression and Globin 
Locus Control Region Function in 
Erythroid Cells 

Howard Lawrence West, magna cum laude 

Clinical and Neuropathological 
Correlates of Apolipoprotein E 
Genotype Subgroups Within the 
Alzheimer's Disease Patient 
Population 



14 



Harvard Medical Alumni Bulletin 



Tadeus John Wieczorek, cum laude 

Response Modulated Excitation With 
Applications 

Stephen Daniel Wiviott, cum laude 

Inhibition of Endogenous Nitric 
Oxide Signaling in Adult Rat 
Ventricular Myocytes Increases 
Contractile Function in a Calcium- 
Independent Manner 



Theodore Tsomides 

James Tolbert Shipley Prize for excel- 
lence and accomplishment in research: 
Anti-Melanoma Cj^otoxic T 
Lymphocytes (CTL) Recognize 
Numerous Antigenic Peptides Having 
'Self Sequences: Autoimmune Nature 
of the Anti-Melanoma CTL Response 



Patricia Lee 



Deborah Lee Cohan and Joshua Moses 
Sharfstein 

The Community Service Award to the 
seniors who have done the most to 
exemplify and/or promote the spirit 
and practice of community service 

Eleanor Ann Drey, Emily Oken and Joshua 
Moses Sharfstein 

Robert H. Ebert Prize for excellence 
and outstanding accomplishments in 
the field of primary care medicine 

Andrew Jeffrey Greenspan 

Kurt Isselbacher Prize to the senior 
demonstrating humanitarian values 
and dedication to science 

Naomi Nichele Duke, Andrew Jeffrey 
Greenspan and Brent Oliver Hale 

The Multiculturalism and Diversity 
Award: to the seniors who have done 
the most to exemplify and/or promote 
the spirit and practice of multicultural- 
ism and diversity 

Beth Ellen Ebel 

The New England Pediatric Society 
Prize to the senior who in the opinion 
of peers and faculty best exempfifies 
those qualities one looks for in a pedi- 
atrician 

Joshua Moses Sharfstein 

Rose Seegal Prize for the best paper 
on the relation of the medical profes- 
sion to the community: Campaign 
Contributions From the American 
Medical Political Action Committee to 
Members of Congress 





Autumn 1996 



15 



The Joy and Solace 
of Surgery 



by Joseph E. Murray 



A quilt of 



memories 

Being with you at this unique 
rime in your lives is unquestionably 
die high point of my professional year. 
HMS has influenced my life for over 70 
years. As a young boy I would fre- 
quendy ride with my dad along 
Longwood Avenue. Looking across 
the Quadrangle flanked by these mar- 
ble buildings, I intuitively knew that 
this is where I wanted to go to medical 
school. 

I selected this title because 
although joy and solace can of course 
emerge from other disciplines, I am a 
surgeon. From earUest childhood I 
knew I would be a surgeon. There 
were no physicians on either side of 
my family. But perhaps I was influ- 
enced by our family doctor whose very 
presence during our childhood ill- 
nesses brought an almost miraculous 
sense of caring and security into our 
home. 

Fifty-six years ago, in September 
1940, 1 first arrived at Vanderbilt Hall. 
My four years at HMS were all that I 
dreamed they would be. Classmates 
and faculty were stimulating and 
friendly. Hospitals were filled with 
varieties of patients. Although the 
hours of study and hospital duty were 
long, life was rich and full. Symphony 
Hall and Gardner Museum were 




within walking distance, squash courts 
were available for daily exercise, our 
singing group met weekly in the club 
dining room. Weekend bicycle trips 
(wartime gas rationing was in effect) 
and club dances added to the variety of 
activities. As I commented in a brief 
preamble to my Nobel address, "It was 
heaven!" 

Each of you will follow your own 
dream, within or outside of medicine. 
As physicians, we have a glorious her- 
itage and mission for life — a combina- 
tion of the best of humanity and the 
best of science. My lifetime in surgery 
has created an elegant spiritual tapes- 
try — of patients and their families, 
medical and nursing colleagues, stu- 
dents and residents, senior investiga- 
tors and research fellows, social 
workers and administrators — all woven 
together in a marvelous quilt of mem- 
ories. 

During World War 11, medical 
school courses and residencies were 
accelerated. Our Class Day was cele- 
brated in the Vanderbilt gym on 
December 31, 1943. President Conant 
was our speaker. Our entire class was 
in military uniform, we in the army as 
privates, those in the navy as officers! 
(We army guys drilled early every 
morning in the Vanderbilt parking lot, 
while our navy classmates hooted at us 
from their windows.) 

My surgical "interneship" at the 
Brigham (then known as the Peter 
Bent Brigham Hospital) started on 
January i, 1944, the day after gradua- 



tion. Surgery has grown phenomenally 
since then. At that time, most opera- 
tions were excisional, for example, 
amputations, appendectomy, cholecys- 
tectomy, hysterectomy. My interne- 
ship was only nine months long. 

At Valley Forge General Hospital 
in Pennsylvania, a plastic surgical cen- 
ter to which I was randomly assigned 
for my first military duty, we treated 
battie casualties from the European, 
African and Pacific theaters. I reveled 
in the technical challenges of recon- 
structive surgery, imaginatively restor- 
ing noses, ears and eyelids, rebuilding 
arms, hands and legs, resurfacing 
severe burns, while at the same time 
trying to restore the morale of these 
severely damaged soldiers. 

Four hundred years ago the father 
of plastic surgery, Gaspare Tagliacozzi 
of Bologna, noted the psychological 
benefits of reconstructive surgery: 
"We repair those defects that nature 
and ill fortune have taken away, not so 
much that they improve the appear- 
ance, but that they restore the spirit of 
the afflicted." Paradoxically, it took the 
ugliness of war for me to appreciate 
the intrinsic value of cosmetic surgery. 

After three years in the military, I 
returned to the Brigham and 
Children's hospitals in November 
1947 to complete my surgical resi- 
dency. At the Brigham I was attracted 
to the kidney transplant program 
under George W. Thorn and Francis 
D. Moore '39, two of the most creative 
and productive clinical scientists of 



16 



Harvard Medical Alumni Bulletin 



this century. Conceptually, transplan- 
tation seemed an extension of recon- 
structive surgery: 'If you can't fix it 
replace it'. 

In this current decade, another cat- 
egory of surgery is evolving, inductive 
surgery. Mechanically induced skin 
expansion and elongation of bones are 
physiological techniques now available 
to treat congenital, traumatic and neo- 
plastic conditions. The increasing 
knowledge of growth factors, adhesion 
molecules and genetic homeoboxes 
may lead to the production of new tis- 
sues and organs for reconstruction and 
transplantation. The possibilities are 
limited only by our imagination. 

I have operated on hundreds of 
patients on all six continents. These 
include patients with militar}', vehicu- 
lar and industrial trauma, children and 
adults with head and neck neoplasms, 
severe thermal bums, extensive birth 
defects, and patients dying of kidney 
failure. I welcomed surgical challenges; 
"Difficulties are opportunities" is a 
slogan I learned from my leprosy 
patients in India. In all my years and 
experiences I have never found any 
reason to alter my basic motives for 

Dean Tosteson greets Neal Baer and son; Ed Hundert waits to 



becoming a doctor: to prevent and 
treat disease, to relieve pain, and to do 
no harm. I did not become a doctor to 
hasten death or to prolong suffering. 

As one involved in human trans- 
plantation from its beginning, I have 
participated in many conferences on 
ethics. Our successful human kidney- 
transplants in the early 1960s created 
the need to formulate "a definition of 
death" based on cessation of brain 
function (Henry K. Beecher chaired 
the committee). The concept of brain 
death as we define it now extends far 
beyond transplantation and is used 
with modifications in emergenc}' units 
and intensive care wards worldwide. 

Physician assisted suicide is a cur- 
rent topic of popular discussion. Last 
week an ethicist from the Netherlands 
told me of a backlash developing in his 
countr}' from the use of physician 
assisted suicide by hospitals and physi- 
cians. Patients are losing trust in the 
medical profession and fear that deci- 
sions about their lives may be based 
more on economic rather than medical 
indications. This is one of the saddest 
commentaries about our profession 
that I can imagine. 

hand over his degree. 




A recent speaker here at Han-ard 
noted that the support for physician 
assisted suicide often arises because of 
inadequacies within the medical pro- 
fession — failure to control pain, or 
insufficient social support for the 
patient and family. I agreed with her 
analysis, but not with her conclusions. 
In my opinion, the proper solution is 
better education and more compas- 
sionate involvement of the physician, 
not the killing of the patient. 

An example of compassionate care 
is an episode that occurred at the 
Brigham 30 or 40 years ago during 
early morning rounds with the late J. 
Englebert Dunphy '33.* Feehng 
pressed for time, Dunphy's resident 
suggested that they skip seeing a cer- 
tain patient that morning because 
nothing had changed in the pre\ious 
24 hours, and besides, the patient had 
incurable cancer. Dunphy stopped, put 
his arm gently over the resident's 
shoulder, and quietly said, "I cure him 
ever}' morning." 

i\Iy decisions about the beginning 
and end of life reflect the spirit of 
Albert Schweitzer — physician, theolo- 
gian, musician — ^who summed up his 



A Collage 
of Talents 

Who are the people behind the 
faces of the Class of 1996? 
"They are a marvelously eclec- 
tic group of talented individu- 
als," says Edward Hundert '84, 
who as associate dean for stu- 
dent affairs has come to know 
every one of them. 

Out of 158 students graduat- 
ing, only 80 took the typical 
four years to complete their 
medical studies. More and 
more students are taking 
longer to graduate to pursue 
other degrees, research, com- 
munity or overseas experi- 
ences, or personal leaves. 
Another trend is the accep- 



AUTUMN 1996 




Castle Society master, Marian Neutra, congratulates Deborah 

philosophy in three words: reverence 
for hfe. When my own patients 
reached the end of the road and were 
just hanging onto Hfe after all treat- 
ments had failed, I would reassure 
them and their families that pain will 
be effectively treated, open sores 
cleansed, and the patient allowed to 
die with dignity. We have no control 
over the moment of our birth; neither, 



Cohen 

in my opinion, should we decide the 
moment for death. The Lord's Prayer 
takes precedence, "Thy will be done." 

Just as physicians should be com- 
passionate, we must at the same time 
comply with the rigors of science. The 
clinical scientist plays an essential role 
in the progress of medical care. In our 
practices we can detect problems 
demanding solutions. Although one 



can rarely, if ever, be both an expert 
clinician and a skilled bench scientist, a 
motivated cHnician can, with extra 
effort, learn and use the elements of 
related laboratory disciplines. The role 
of an MD vis-a-vis PhD in research is 
determined by the individual. With 
realistic priorities and teamwork, he or 
she can be productive in both basic 
and apphed science. As Pasteur wrote, 
"There is only one science." 

Transplantation biology is a para- 
digm for the melding of clinical skill 
with basic science. Organ transplanta- 
tion developed because we clinicians 
needed better treatment for end-stage 
renal disease. The motivation was 
relentiess; large numbers of patients, 
usually young and otherwise healthy, 
were dying. We could not afford to 
wait for the bench scientists to solve 
the problem. But we clinicians could 
not do it alone. Sound soHd experi- 
mentation requires knowing the fim- 
damentals of other disciplines — 
immunology, zoology, genetics, bio- 
chemistry, veterinary medicine, among 
others. 

Service to society is the ultimate 
reason for the existence of the medical 



tance of more older students 
who have had other careers 
before medicine. The stories of 
what students do with their 
year off and what they have 
done before arriving here are 
as diverse as the class. 

This year there was a surge in 
the number (ten) of students 
selecting emergency medicine 
as a specialty (a national trend 
as well), and the television 
show E.R., and thus Neal Baer 
'96, must share some of the 
credit. He took a year off after 
third year to be one of six 
scriptwriters for the show and 
was responsible for developing 
medical stories, advising other 
writers on the medical aspects 
of their script, and writing his 
own scripts. (The pilot script 



for the show was written by 
Michael Crichton '69.) Baer 
has a master's in education, a 
master's in sociology, and had 
developed his interest in 
screenwriting while on a fellow- 
ship at the American Film 
Institute in Los Angeles. He 
had already done some writing 
for films and a television pilot 
before coming to HMS, where 
in his spare time he directed a 
Boston outreach program in 
the public schools and did 
some research on the cell cycle 
at Children's. It is pediatrics 
and not emeigency medicine, 
however, that Baer sets his 
sights on. 

Judith Edersheim '96 gradu- 
ated from Harvard Law School 
in 1985 cum laude, with an 



interest in the underlying 
assumptions about the nature 
of human rationality and the 
relationship of logical argu- 
ments to emotions and preju- 
dice. As she began the practice 
of law, she became interested 
in medicine and volunteered 
legal services at the Family 
Center, an outpatient mental 
health center. Deciding that 
she wished to leave "the often 
artificial abstraction of law for 
the immediacy and importance 
of medicine," she took pre- 
med courses at Wellesley 
College and was admitted to 
HMS in 1991. (She took a year 
off after first year to be with 
her infant son.) She is now 
training in psychiatry at 
Cambridge Hospital in 
Massachusetts. 



After graduating magna cum 
laude from Williams College, 
where she was captain of the 
women's ice hockey team, Beth 
Ebel '96 was selected as a 
Rhodes Scholar and spent 
three years at Oxford. She was 
conferred a master's of sci- 
ence in developmental econom- 
ics, writing her thesis on the 
impact of food subsidies on 
poverty in the Sudan, and 
received a commendation for 
overall highest marks. After a 
job with the United Nations 
Development Program in New 
York, Ebel coordinated a study 
of options for financing health 
care in developing countries 
for UNICEF for two years. For a 
year before starting at HMS in 
the HST Division, she was the 
socioeconomic advisor for 



Harvard Medical Alumni Bulletin 



profession. The clinical scientist serves 
society by acting as a two-way bridge 
betw^een bed and bench. Everyone 
benefits, especially patients. An effec- 
tive clinical scientist must be a team 
player and have only three qualities: 
curiosity, imagination and persistence. 
Curiosity about how nature works, 
imagination to detect a nexus between 
seemingly unrelated observations, and 
persistence in face of disappointment. 

When I spoke at HMS commence- 
ment five years ago, my tide was from 
Browning, "The Best Is Yet To Be." 
This applies even more so today. You 
are graduating at the best time in his- 
tory for the effective care of patients. 
Cellular and molecular biology, genet- 
ics, tissue induction and surgical tech- 
niques have progressed rapidly. I have 
not operated now for ten years, and I 
readily admit that some of today's pro- 
cedures have advanced far beyond me. 

Before I conclude, I wish to empha- 
size that I am well aware of the heavy 
financial burdens most of you have 
accumulated during your years of edu- 
cation. This is probably the most criti- 
cal problem in medical education 
today. In addition, you face the worri- 




Kingsley Chin 

some influence of managed care and 
its effect on your treatment of patients. 
But it would be counterproductive to 
allow these ephemeral problems to 
insulate you from the warmth and 
richness to be experienced in our pro- 
fession. Every decade has its problems. 
Ours was World War II; some of our 
group never did return, others had 
careers aborted. No matter what, our 



ideals can remain immutable. 

I will conclude with personal reflec- 
tions about which I feel strongly. But I 
hasten to add that I am sensitive to and 
respect those with differing opinions. 
A philosophy of death seems to be 
creeping into society. Like everyone 
else, I am appalled by the meaningless 
destruction of human life seen and 
reported daily in the media. 



UNICEF in Quito, Ecuador, 
wliere she worlted to improve 
access to heaitli care. Ebel was 
tlie founder, coach and star of 
the HST Blades, an HMS/MIT 
ice hocltey team. She plans to 
continue her career in interna- 
tional health after a residency 
in pediatrics at Johns Hopkins. 

After escaping with his family 
from war-torn Vietnam in a 
boat, Vincent Trien-Vinh Ho '96 
spent a year in a Malaysian 
refugee camp, where—exposed 
to hardships and atrocities — 
he determined he would go into 
medicine someday. At Boston 
Latin, he placed first in the 
Massachusetts State Science 
Fair and was tournament 
champion in table tennis his 
senior year. At Harvard, he 



taught and directed an English 
as a second language program 
for refugee teenagers and 
senior year, working in the lab- 
oratory of Alan D' Andrea at the 
Dana-Farber Cancer Institute, 
isolated an important mutant 
of an oncoprotein that causes 
murine erythroleukemia. 
Through a public service fel- 
lowship, he took a year off 
before medical school to teach 
English to refugees at a camp 
in the Philippines. He's now a 
resident in internal medicine at 
Brigham and Women's 
Hospital. 

Manish Bhandari '96 has dis- 
tinguished himself both as a 
scholar and as a humanitarian. 
He grew up in India and spent 
his summer vacations in high 



school working with Mother 
Teresa in Calcutta. While gar- 
nering a range of prizes and 
awards in molecular and cell 
biology at University of 
California, Berkeley, he also 
ran Berkeley's student tutoring 
program and was a Red Cross 
Relief worker after the Bay 
Area earthquake in 1989. After 
first year at HMS, he traveled 
to the Kanti Children's Hospital 
in Nepal on a Paul Dudley 
White Fellowship. Stirred by 
the hospital's lack of basic 
resources — sutures, syringes 
and latex gloves — Ghandari 
established a nonprofit 
organization, Resources 
International, to collect and 
disperse to the Third World 
spare supplies and equipment 
from Boston-area hospitals. He 



held off a year to graduate so 
he and his wife, Shalini Gupta 
'96, could participate in the 
couples match this year. He is 
a resident in internal medicine 
at Brown, where Gupta is in 
plastic sui^ery. 

Ellen Barlow 



Autumn 1996 



19 



\^"orld\vide nationalistic, religious, 
political and tribal mass destructions 
are commonplace. I am staggered by 
the fact that over one and a half mil- 
lion normal fetuses are destroyed 
annually in the United States. 
Destruction of life at both its begin- 
ning and end is becoming mainstream. 
We know from sad experience how 
easily governments, tribes, gangs, and 
even yoimg children can justify killing. 

The medical profession is the ulti- 
mate bulwark for society against any 
culture of death. I am optimistic that 
future knowledge and understanding 
will at least partially help to blunt cul- 
tural and spiritual differences. We 
know that it is "better to light a candle 
than to curse the darkness." As physi- 
cians we can carry the candles of light 
by ministering to our patients and 
families, by teaching and learning 
along with our students, and by inves- 
tigating the mysteries of nature. 

My own life's journey has been 
guided by Schweitzer's motto "rever- 
ence for life," the Hippocratic Oath, 
and Harvard Medical School, which 
for me has been a perpetual Fountain 
of Youth. '^ 

Joseph E. Murray '45 B is professor of 
surgery emeritus at Harvard Medical 
School, and for 54 years was chief of the 
Division of Plastic and Reconstructive 
Surge?j at both the Brighain and 
Women ^s and Childrett ^s hospitals. 
He was a co-recipient of the igpo 
Nobel Prize in Physiology or Medicine. 

*J. Englebert Dunphy '53 was David 
Cheever Professor of Surgery and surgeon- 
in-chief of the Harvard Service at Boston 
City Hospital, and was a president of the 
Harvard Medical School Alumni 
Association. For years a copy ofDunphy's 
ip'j6 oration to Massachusetts Medical 
Society, "On Caring for the Patient with 
Cancer, " was given to each HMS graduate 
along with Francis Peabody's "Caring for 
the Patient. " 




Joshua Sharfstein 



Prepared for 
the Future 



by Joshua Sharfstein 



The party is over and ifs time to 
get a] oh I 



20 



Harvard Medical Alumni Bulletin 



Commencement is a wonderful 
occasion — but let's face it, in a few 
hours the party will be over. This tent 
will come down, these chairs will be 
put away. Dean Hundert will have to 
put his clothes back on... and then 
what? 

If you are thinking, and then we go 
on to residency and become practicing 
physicians, I've got news for you. I 
have today's Wall Street Journal and 
I'm going to read you a headline: 
"Looking for an Easier Job, Harvard's 
Dean Tosteson to Seek Russian 
Presidency." I'm sorry — that's not the 
headline I meant to read. Here it is: 
"Citing Budget Crunch, U.S. 
Hospitals Eliminate Residency 
Programs." 

That's right: we all need jobs. So I 
don't think this is an entirely inappro- 
priate time to consider the difficult 
question, "What have we really 
learned at HMS that will help us in the 
future?" 

I started thinking about this ques- 
tion by making a list and reading it 
over and over again. And I realized 
that the first thing we've learned here 
is how to make a list and read it over 



and over again. That's the key to con- 
structing a complete differential diag- 
nosis. And while we may have been 
bored at the time, let us recognize that 
famiharity with lists is a marketable 
skill that will serve us well in a wide 
variety of positions, such as telephone 
operator, tax lawyer and traveling 
salesperson. 

We have also learned to memorize. 
Over the last four years, we have each 
memorized thousands of pieces of 
information, from irrelevant trivia, 
such as the percentage of people who 
do not naturally have a palmaris 
longus muscle, to essential facts, such 
as the person on call the first Friday of 
a month-long Q4 rotation gets no 
golden weekend. Perhaps most telling, 
I've memorized all nine diagnostic cri- 
teria for obsessive compulsive person- 
ality disorder. No doubt, these 
memorizing abilities will serve us well 
in a wide range of careers, to name just 
a few: telephone operator, tax lawyer 
and traveling salesperson. 

In addition to the nerdy, cerebral 
skills of list-making and memorization, 
we have not been afraid to get our 
hands dirty at HMS. Recall for a 



moment the times we woke up early to 
retract in surgery, the times our dental 
colleagues worked late in clinic pulling 
teeth, and the times that we retracted 
in surgery for so long that it felt like 
our dental colleagues were right there 
with us, pulling our teeth. Fortunately, 
manual skills will help us as telephone 
operators, tax lawyers and traveling 
salespeople. 

Earlier I asked,"What have we 
really learned at HMS?" You may be 
mad because in response to that diffi- 
cult question, I've just offered implau- 
sible answers and waved my 
hands — but that's another thing I've 
picked up at HMS. 

Of course, Harvard has prepared us 
for far more than these three careers. 
For example, after our third year on 
call every third or fourth night, we are 
well equipped for many jobs, such as 
overnight camp counselors, nighttime 
security guards and 24-hour conve- 
nience store managers. 

But that is just the beginning. 
Using our knowledge of surgical 
scrubbing and sterile technique, the 
Class of 1996 could create a national 
chain of delicatessens dedicated to new 




Venkatesh Raman, 
Arun Jogi and Edward 
Machtinger 



Autumn 1996 



standards of cleanliness and hygiene. 
Admittedly, it would take 45 minutes 
to make a turkey sandwich. Here's 
another idea: We could form a small 
country, pool our student loans, and 
apply to the International Monetary 
Fund and World Bank for debt relief. 

For such a scheme to work, we'd 
need friends in high places. The good 
news is that Harvard has prepared us 
well for politics. Good politicians 
know that the relationship between 
elected representative and voter is a 
two-way street. Similarly, we have 
learned that the doctor/patient rela- 
tionship is a two-way street, and to be 
effective physicians we can take noth- 
ing for granted in that relationship. 

A joke my grandfather told me last 
night really makes this point well. A 
man has a skiing accident and winds up 



at an orthopedist's office. The doctor 
removes his ski boot and sock and 
finds the dirtiest foot she's ever seen. 
Absolutely filthy. "Haven't you ever 
been to the doctor before?" the doctor 
asks. "Of course," the patient says. 
"Hasn't the doctor ever told you to 
wash your feet?" "Sure," the patient 
says. "So why haven't you?" the doctor 
asks. The patient laughs and says: "Go 
beheve in one doctor!" 

Earlier today, I broke the news to 
my family that we all needed jobs and 
asked for suggestions. My father said 
that with our sense of duty, we could 
become police officers. My grand- 
mother said that with our sense of 
responsibility, we could become 
judges. And my mother said that with 
our sense of entitlement, we could 
become royalty. Thanks, mom. 




Speaking of royalty, it is no secret 
that some of us here hope to become 
health care executives, something we 
have been well prepared for at 
Harvard. I mean, any school that pre- 
pares its graduates to become tele- 
phone operators, tax lavsyers and 
travehng salespeople almost by defini- 
tion trains its graduates to become 
modern health care executives. 

Given the broad preparation we 
have received for the future at HMS, 
what is the single most useful thing we 
have learned? I discovered the answer 
several months ago, when I called my 
grandfather in a Florida hospital, 
where he had been admitted for car- 
diac observation. "Josh," he said, 
"Something is terribly wrong. I can't 
stand it any longer." "What's the mat- 
ter?" I asked. When he told me, I was 
both panicked and confident. Panicked 
because I knew immediately how seri- 
ous the problem was, and confident 
because I had learned the solution on 
the wards at HMS. 

"Grandpa, I want you to do exactly 
as I tell you," I said. "Find the channel 
changer button. Keep it pushed, you'll 
cycle through a few stations and the 
TV will turn off." After a brief pause, I 
heard, "I'll be damned. I've been try- 
ing to get this thing off for an hour. 
There's no on-and-off switch! Now I 
can finally get some sleep." I'm proud 
to report that all of my grandparents 
are here with me today. 

I'll also admit that I lied at the 
beginning of my speech. No residency 
programs have been cancelled; we will 
indeed become practicing physicians. 
Actually, this second newspaper head- 
line here reads "Seeking a Challenge, 
Russian President Boris Yeltsin to 
Become Next Dean of HMS." But at 
least we know, that no matter what the 
future of medicine holds, we will be 
prepared for it, thanks to HMS. ^ 

Joshua Sharfstein 'p6 is an intern in pedi- 
atrics in the combined residency program 
at Boston City Hospital and Boston 'j- 
Children 'j- Hospital. 




There^s nothing 
we can V do 

I REMEMBER MY FIRST DAY AT HMS, WE 
had to introduce ourselves in our tuto- 
rial. Shawn, sitting on my right, had 
raised two kids and went to school at 
the same time. Choll, next to him, 
already had a PhD. Clark was this 18- 
year-old who used to work for Choll, 
but instead of starting college, joined 
him in the same medical school class. 
Jeremy had spent a year at the 
Wharton Business School. GiUian had 
worked in a women's clinic. Lydia 
came from "T.C." or "the college." It 
took me awhile to figure out which 
college! 

If you looked from group to group 
during that first year, you would find 
experts in law, business, the military 
and even professional football. The 
admissions office really did an amazing 
job in recruiting students from nearly 
every professional organization in this 
country. 

I remember thinking to myself, I 
must be the least interesting person in 
my class. It's been almost four years, 
and I still feel that way. I continue to 
be humbled by my classmates and the 



On the Way 
Out of 
Harvard 



^ by Chih -Hung Jason Wang 



things they do. 

The hidden talents of these HMSers 
started to emerge long before the soci- 
ety Olympics and second year show. 
Our HMS soccer team "kicked some 
butt" when they competed against 
other graduate schools. People who 
used to spend hours in the basements 
of labs were now singing with the 
"Countway Basics" and the "Barr 
Bodies." 

We had classmates working on 
urban health projects and those who 
went to Africa and India. In fact, I 
think I was probably the only person 
who didn't go to Guatemala this year. 

With so much talent around HMS, 
the question: Where do we go from 
here? 

I was slighdy disappointed by a 
cover of the Harvard Medical Alumni 
Bulletin, which suggested that the 
answer to that question is already 
determined, that our future is spelled 
out: we are all going to work for HMOs. 
I don't think this issue is setded. 
Perhaps we will all work for HMOs, but 
we will do so only if we agree that it is 
the best way to provide health care. 

There are others who worry that 
research funding at NIH is drying up. 
Perhaps it has become more difficult 
to get funding, but it is now that cre- 
ativity becomes important. We will 



find new ways to fund research, from 
industry and other nongovernmental 
agencies, and by expanding new health 
markets abroad. In the meantime, we 
will use our resources more carefully 
by setting priorities in research. 

I want to urge you, my friends, that 
the luibending spirits that brought us 
to Harvard should not stop here. 
Together, we will be the architects of 
the future of health care and more. 
We will continue to pass on the tradi- 
tion of excellence, dedication and cre- 
ativity. 

So, fellow classmates, when people 
ask you, "What can you do now that 
you are graduating from HMS," look 
around as I have so often done. Look 
around at Clark and Shawn and Choll. 
Look at the person to your left and 
your right. You will answer as I do: 
There is nothing we cannot do. ^ 

Chih-Hung Jason Wang '^6 is the 
author of the 199 s best-selling Chinese 
nonfiction book On the Way to Harvard: 
Experiences of an Immigrant Student 
in America. 



Autumn 1996 



23 



Alumni 




On a sunny cloudless day alumni 
from across the country gathered to 
participate in the festivities of reunion 
week. The hvely spirit of Alumni Day 
was felt on the Quad and in the halls 
of Building A as alumni swapped 
updates and remembered earlier times. 

Dean Daniel Federman '53, direc- 
tor of alumni relations, warmly wel- 
comed everyone before the start of the 
business meeting. Reunion gifts were 
presented to Dean Daniel Tosteson 
'49 by agents for the 25th and 50th 
classes. Ann Stark and Frank Berson 
took charge of the Class of 1971's gift, 
with Stark recalling the Tom Hanks 
character from the movie Big as she 
commented, "It's hard to believe our 
class is comprised of grown-ups!" John 
Braasch presented the Class of 1946's 
gift, noting that not only did his class 
produce two Nobel Prize winners, but 
equally remarkably, one alumnus who 
was currently on his honeymoon. 



The torch was then passed from 
outgoing Alumni Council president 
Stephanie Pincus '68 to her successor 
Suzanne Fletcher '66, signalling the 
end of the business meeting. 

This year's symposium, "Ethics and 
Professionalism Under Managed 
Care," was moderated by Dean 
Federman. Noting that the field of 
medicine is known for its revolutions, 
including the advent of antibiotics and 
Medicaid, Federman distinguished 
between revolutions of old and the 
most recent revolution — managed 
care. Whereas in the past physicians 
have been the leaders in instituting 
changes in the medical field, changes 
taking place today are originating from 
those outside the field — insurance 
companies, the government and other 
nonmedical bodies. 

With that said, Federman ended 
with a quote by Shakespeare, "Things 
are neither good nor bad but thinking 



makes them so," and invited alumni to 
follow the New Pathway model and 
engage in discussion after the 
speeches. 

Nina Tolkoff- Rubin '68, director 
of hemodialysis and CAPD at MGH, 
invoked the early forefathers of medi- 
cine, Hippocrates and Aesculapius, and 
challenged her fellow alumni to 
develop new paradigms in the face of 
economic change. Tolkoff-Rubin, HMS 
associate professor of medicine, 
encouraged the medical commimity, as 
the "children" of these teachers, to 
integrate both their intellectual and 
their moral lessons. 

Associate HMS clinical professor of 
psychiatry James Sabin '64 took on 
Dean Federman's assignment to "be 
amusing, not cite any references, and 
say something personal" in relation to 
ethical decision-making in a managed 
care environment. Sabin, associate 
director for teaching programs at 



24 



Harvard Medical Alumni Bulletin 




m ft 




Harvard Community Health Plan, 
reflected on his more than 20 years as 
a practicing psychiatrist at HCHP, 
founded by Dean Robert Ebert and 
now called Harvard Pilgrim Health 
Care. Sabin confessed that rather than 
spending time on major ethical issues, 
such as resource allocation, he spends 
more of his time on how to manage his 
time. After all, he said, he is essentially 
responsible for the whole HMO popula- 
tion, not just his current patients. 
Sabin emphasized the importance of 
the doctor/patient relationship and 
dealing openly with the patient about 
the constraints imposed by a managed 
care setting. 

Sabin's belief that doctors and 
patients need to work together 
prompted a variety of comments from 
the audience, particularly from those 
in the field of psychiatry. 

John Appel '36 was the first of sev- 
eral members of the psychiatric com- 



munity to take their place in front of 
the microphone, wondering how clini- 
cians should go about allocating their 
time and effort to patients in therapy 
in the context of the current climate. 

The dilemma of balancing the 
costs of therapeutic drugs with good 
patient care was introduced by John 
Hamilton '71. Hamilton bemoaned 
the complexity of decision-making 
when trying to be attentive to a health 
plan's Hmitations while doing what's 
best for the patient. Another therapist 
in the audience noted that she had 
avoided difficult decisions about whom 
to see by choosing only those patients 
she liked, wondering now if that prac- 
tice was "ethical." 

Bruce Sams '55 called for doctors 
to make a difference in the arena of 
managed care by finding ways to exert 
control. All were reminded by Joe 
Foley '41 that medical care is a right 
and not a privilege. Foley hoped those 



present could resist transforming a 
moral issue into an economic one. 

The question and answer period 
before the break was poignantly ended 
by second-year student Maisha Draves 
who came out to the symposium as a 
breather from studying for her Boards. 
She lamented the schism growing 
between her tuition costs and her 
potential to pay these bills in a capi- 
tated environment: "We have to pay so 
much to become doctors. Now our 
salaries will be capped and limits put 
on our practices. We are so frightened, 
wondering why it is we came into 
medicine." 

At that point, Federman took the 
opportunity to announce the develop- 
ment of a new HMS course, the 
"Clinical Commons," which, among 
other issues, will address student debt. 
Also noted was the Alumni Fund's 
decision to continue to focus on stu- 
dent debt in the year ahead. 



Autumn 1996 



25 



.\11 were admonished to take no 
more than 1 5 minutes to stretch their 
legs and grab a snack as there was 
much more to come. Fortified by 
reireshments and fively conversation, 
alumni then returned for the second 
part of the s\Tnposiuni. 

In his introductory comments 
Kenneth Shine '61 reflected that he 
was one of the first pair of students 
Dean Federman supervised as an 
attending. Shine, president of the 
Institute of Medicine, National 
Academy of Sciences, offered his fore- 
cast of what was to come in the world 
of health care, including an increasing 
amount of regulation by the states. 
Adding to the many comments about 
how doctors and patients should work 
together and who should exert control. 
Shine stated that the goal of doctor 
control was self defeating, and instead 
advocated for doctor/patient collabo- 
ration in the next decade. He also 
urged doctors to form alliances with 
their patients at both the community 
and state levels to monitor quality of 
care. 

Strajdng from recent tradition, the 
last speech was given by an intern 



ratlier than a medical student. Joshua 
Hauser, an intern in medicine at 
Brigham and Women's, spent a year 
studying ethics in the Division of 
Medical Ethics at HMS before begin- 
ning his internship. Hauser spoke 
about the challenges he and other 
interns face daily to retain their empa- 
thy with patients. He implored his col- 
leagues to go beyond the traditional 
questions when taking a history and 
personally explore who is sitting in 
front of them. 

With that injunction, it was time 
for more comments and questions. 
Peter Liebert '61 observed that doc- 
tors need to educate their patients 
about managed care, while recent 
graduate Anna Birkenblit '96 sug- 
gested medical students should know 
about quality assurance tools in order 
to deal with what's to come in the 
future. 

Dean Federman summarized that 
everything touched on during the 
symposium and discussion periods was 
really at the core of the patient/doctor 
relationship. Federman also had some 
words of advice for the various con- 
stituencies in the audience who might 



want to continue this discussion: "If 
you're an intern, go to sleep. If you're 
a yoimg alum, find us [the alumni asso- 
ciation] on the World Wide Web. If 
you're an older alum, ask your grand- 
child to find the Web. And if you're 
older than that just stay well and come 
back to the next reunion!" 

The morning was topped off by 
Dean Tosteson's report on the events 
of the past year. Noting that this was 
the 1 06th aimiversary of the Alumni 
Council, Tosteson provided an update 
on the faculty: 54 individuals became 
full professors, bringing the total to 
475 of 13,000 faculty appointments. 

In 1996 158 MDs graduated, 23 
with combined degrees and 26 with 
honors. The class of 2000 attracted 
4,500 applicants; of the 165 accepted, 
2 3 percent are members of a minority 
group, up from last year's 16 percent, 
and 55 percent are women. 

Two emeritus faculty who passed 
away in the last year, Robert Ebert and 
Cliff Barger '43A, were acknowledged 
in a moment of silence. Tosteson then 
reviewed new appointments and some 
HMS creations in the past year, such as 
the Division of Emergency Medicine 




Collins Lewis '71, Ann 
Stark '71 and fellow 
alumni. 



26 



Harvard Medical Alumni Bulletin 



and the course "Clinical Commons." 
This course reflects the restructuring 
of the first six months of the Patient- 
Doctor III course, which should give 
students more experience in the ambu- 
latory care setting. Each student will 
do a third month of medicine and a 
third month of surgery in an ambula- 
tory care setting. 

The Faculty Council approved a 
reduction in the unit loan from 
$25,000 to $20,000, effective with the 
incoming class. This was made possi- 
ble by a gift designated for scholarship 
by James Stillman '32 of close to $10 
million. The goal is to raise enough 
funds to reduce the unit loan to 
$15,000 over the next five years. In 
addition, the medical school has raised 
$171.7 million, closing in on its $220 
million goal for the university cam- 
paign. 

And lastly, Dean Tosteson read his 
letter to President Rudenstine in 
which he states his intention to step 
down as dean in 1997. 



The 

Unsteady 
State of 
Health Care 



by Kenneth I. Shine 




alliances are 
critical to the 



outcome 

Systemic, comprehensive federal 
reform of the American health care 
system is not on the horizon for the 
foreseeable future. The federal gov- 
ernment will have a role to play in the 
next several years, however. That role 
primarily will be to produce incremen- 
tal changes in Medicare/Medicaid and 
in care for some special populations, 
and to rationalize state regulation of 
the health care enterprise. The most 
important changes will continue to 
take place in various states, but the 
federal obligation will be to rationalize 
these changes, assure the comparabil- 
ity of information and, ultimately, 
resolve conflicts produced by state 
lines. 

In this context, I would like to sug- 



gest the critical role of well-informed 
joint patient/doctor decision-making 
as the central theme around which the 
role of the health professions and qual- 
ity of health care ought to be centered. 

Substantial change in the 1980s 
nonsystem we called "health care" was 
inevitable. The historical fee-for-ser- 
vice practice of medicine rewarded 
overutilization, redundancy and until 
recently, used science and technology 
in practice, but paid little attention to 
practicing in any scientific way. We 
developed enormous excesses in capac- 
ity, with twice as many hospital beds as 
needed for many parts of the country. 
We educated too many physicians and 
made too Httle use of integrated teams 
of health care providers. 

While almost every other segment 
of the economy used technology in 
improving the efficiency with which it 
functioned, the medical profession and 
health care institutions were unable or 
unwilling to do so. We talked about 
quality, but did not engage in continu- 
ous quality improvement in any con- 
certed way. 

The movement toward controlling 
health care costs by employers began 
before the Clinton attempt at health 



Autumn 1996 



27 



care reform and had reached signifi- 
cant stages of development in 
California, Minnesota, Oregon and 
Arizona. Altliough few of us would 
organize an employer-based health 
care system if we were creating it 
anew, there are powerful forces that 
will maintain employer-based health 
coverage as a central theme in our 
society. 

Although many of us would favor a 
single-payer health care system, possi- 
bly including the expansion of 
Medicare, I believe we vvdll not see a 
serious consideration of this approach 
for another decade, if ever. It is worth 
reminding those who look wistfully 
toward our Canadian neighbors, where 
the proportion of gross domestic prod- 
uct (GDP) expended for health care has 
diminished from about 10.2 percent to 
9.2 percent, that the Canadian system 
is a provincial system with health plans 
varying significantly from one 
province to another. The proportion- 
ate federal contribution to health care 
is significantly smaller than the federal 
contribution in the United States. 

Moreover, the same kinds of 
painful consolidations taking place in 




Kenneth Shine and Daniel Fedemian 

this country are occurring there, apace 
with an increasingly unhappy medical 
profession that once looked south of 
the border for professional opportuni- 
ties to escape that system. I recently 
attended the annual meeting of the 
Ontario Medical Association in which 
the anger, unhappiness and distrust 
were extraordinarily overt, and physi- 
cians were greatly frustrated that the 



physician surplus in the United States 
was significantly limiting their options. 

It is clear that in the United States 
we must manage health care. We must 
tmderstand what we do, how we do it, 
and what the results of those actions 
are. We must find ways in which tech- 
nology does not simply add to costs 
but in fact controls their rate of 
growth. The movement toward con- 



Symposiac 
Moments of the 
Class of 1971 



Gene-based diagnostics and 
the impact of violence were the 
hot topics of the day at the 
Class of 1971's symposium on 
June 6. While molecular genet- 
ics has become a familiar if 
controversial part of the med- 
ical tapestry, it was only a bud- 
ding science when this class 
graduated 25 years ago. Stuart 
Orkin '71, Leiand Fikes 
Professor of Pediatric Medicine 
at HMS, equated the intellec- 
tual revolution in genetics and 
its application in the seventies 
and eighties to the blossoming 
of physics in the early 1900s. 
The first great success in 
genetics was the prenatal diag- 
nosis of thalassemia, which 
can cause fatal anemia. The 
science of molecular genetics 
is now well established in the 



clinic and there are genetics 
tests for over 200 diseases. 

Roberta Pagon '71, professor 
of pediatrics at the University 
of Washington School of 
Medicine, is directing the 
development of two informa- 
tion systems to help busy med- 
ical practitioners wade through 
the overwhelming number of 
genetics tests now available. 
The first, Helix, is a national 
directory of DNA diagnostic 
laboratories, in which the 
physician can look up informa- 
tion by phone, fax and the 
Internet. The second is 
Genline, which provides a dis- 
cussion forum for a number of 
issues surrounding these tests, 
including their quality. 



The second part of the morn- 
ing's symposium was devoted 
to the impact of violence. 
Moderator Cynthia N. Kettyle 
'71, clinical instructor of psy- 
chiatry at HMS, and director of 
medical student education in 
psychiatry, spoke on how the 
role of the physician in dealing 
with violence and its sequelae 
has changed since she gradu- 
ated from HMS. Twenty-five 
years ago she regarded vio- 
lence as a personal and social 
crisis that interfered with the 
physician's ability to do his or 
her job. "Now it is indisputable 
that diagnosing and treating 
violence and its impact on the 
lives of our patients are central 
to the physician's role." 
Parallel to the evolution in her 
own thinking, she said, certain 



28 



Harvard Medical Alumni Bulletin 



solidation of institutions, providers, 
pharmaceutical and device manufac- 
turers, and academic health centers is 
inevitable in view of the very substan- 
tial excess capacity that we have gener- 
ated, with littie attention to the added 
value that additional expenditures pro- 
vide. 

We are nowhere near a steady state 
in the organization of the American 
health care system. Consolidations are 
likely to increase until most metropoli- 
tan areas have between two to six 
major networks of care for 70 or 75 
percent of the population. Fee-for-ser- 
vice medicine will persist for perhaps 
10 to 12 percent of the population, not 
unlike what has happened in Great 
Britain. A grovdng concern for all of 
us is the nature of the health care pro- 
vided for the increasing numbers of 
uninsured individuals (now exceeding 
40 million) for whom access to health 
care and health insurance is wanting. 

My own view is that Americans will 
prefer a diverse health care system 
with a variety of organizations and 
care provided by both the public and 
the private sectors. Although we can 
learn from the details of other health 



care systems, there is no ideal health 
care system to which we can aspire 
and, like many other things, the solu- 
tion for America will be uniquely 
American. 

We will continue to have for-profit 
and not-for-profit activities, although 
the large for-profit managed care 
organizations will see profit margins 
dramatically decrease as excess capac- 
ity is wrung out of the system. As we 
are begiiming to see in California and 
Minnesota, employers are now 
increasingly committed to understand- 
ing the value provided by health care 
dollars on behalf of their employees. 
We must take advantage of that inter- 
est. With consolidation, regulation 
will be required. 

Within a few years, we will think 
about health care as a regulated utility. 
As such, prices will be determined by a 
market mechanism, but regulators will 
set an increasing number of conditions 
for the utility's activities. These will 
include rules about portabihty, move- 
ment across state lines and out-of-area 
treatments. It will include the necessity 
for accurate measurements of out- 
comes and quality of care in units 



comparable from one part of the coun- 
try to another. In some cases, these 
requirements will arise out of the 
Health Care Financing Administra- 
tion, as an increasing proportion of 
Americans receiving Medicare will 
enter managed care, regardless of any 
federal legislation. Similarly, almost all 
Medicaid recipients will be in a man- 
aged care system. 

Although I have been predicting 
the development of the regulated util- 
ity for several years, I am always sur- 
prised by the velocity of change. I 
suggest that the development of laws 
in 1 3 or more states on excluding gag 
rules, the legislative activities on 
length of stay after vaginal delivery or 
Cesarean section, and the extensive set 
of regulatory requirements introduced 
by Governor Pataki in New York 
reflect the beginning of this regulatory 
activity. Ultimately, the federal gov- 
ernment will have to become involved 
in the process in order to rationalize 
these regulations. It was not surpris- 
ing, therefore, that in May a House 
committee held hearings on gag rules 
(i.e., rules limiting what a physician 
may tell a patient) and will consider 



changes in medical student 
education at HMS have 
occurred that are designed to 
enhance the students' aware- 
ness of violence and its ramifi- 
cations. 

David Bear '71, professor of 
psychiatry at the University of 
Massachusetts Medical Center, 
presented the anatomy of 
aggression from a neurological 
perspective. Bear discussed 
the importance of doing an 
organic evaluation of patients 
who exhibit aggressive behav- 
ior. A neurological model of 
aggression may also assist 
doctors in the treatment of this 
behavior, and help them sort 
out external and internal trig- 
gers of aggression. 



David Spiegel '71, professor of 
psychiatry and behavioral sci- 
ences at Stanford University 
School of Medicine, gave a pre- 
sentation entitled "Souvenirs 
of Stress: Acute and Post- 
Traumatic Stress Disorder." 
Spiegel described patients' 
responses to violence, natural 
disasters and life-threatening 
illness. He also discussed the 
treatment of patients with 
stress disorders through 
means of psychotherapy, psy- 
chopharmacology and social 
support, i.e., group therapy. 

This part of the symposium 
concluded with a presentation 
by Mark Rosenberg '71, direc- 
tor of the National Center for 
Injury Prevention and Control 
at the Centers for Disease 



Control and Prevention on 
"Violence Prevention: A 
Personal Perspective." 

The Class of 1971 also partici- 
pated in an eclectic event enti- 
tled "Personal Odysseys." 
Magruder Donaldson '71, mod- 
erator, greeted the packed 
amphitheater with some 
humorous observations. 
Beekeeping is one of his hob- 
bies, and he likened the return 
of his classmates to HMS to 
that of bees to "the hive," 
equating the back and forth 
between returnees as the same 
as "the dance that bees do 
when they get together." But, 
since this part of the day got 
started after a generous buffet, 
with somnolence-inducing 
pasta, he expressed some con- 



cern about the post-lunch sero- 
tonin levels of his audience. He 
need not have worried since 
each presentation held the 
attention of the audience. 

Alexandra Murray Harrison 
'71, an assistant clinical pro- 
fessor of psychiatry at HMS, 
discussed the relationship 
between her chosen profession 
and her family life. "What is 
HMS not so good at teaching?" 
she began by asking. Her 
answers were "ambiguity, igno- 
rance (not knowing solutions), 
helplessness, tolerating 
patient's pain (and one's own) 
and disappointment (not living 
up to one's own standards)." 
These are things she had to 
learn in her personal life. As 
the mother of two children with 



Autumn 1996 



29 



federal legislation in diis arena. 

There are three major elements 
that have to be confronted as these 
changes take place: i) protecting the 
relationship between health provider 
and patient; 2) moving from a system 
that rewards excess care to one that 
rewards underutilization of resources, 
thereby threatening quality of care; 
•and 3) addressing the need for limita- 
tion of resources, producing what has 
been called "rationing." I would 
remind you, however, that today we 
ration health care in the United States 
extensively by limiting eligibility for 
Medicaid and by limiting access for 
the uninsured and for people in rural 
and many urban centers. 

Well-informed joint patient/doctor 
decision-making should be a paradigm 
accepted throughout our health care 
system. All these words are important. 
"Well-informed" means that rapidly 
developing information systems about 
the nature of care and its outcomes 
must be available to both doctor and 
patient so that values and the value of 
the procedure are both part of the 
decision-making process. Just as it is 
important for the referring physician 



to know the quality of care and the 
outcomes related to procedures, it is 
also important for the patient to be 
fully informed. 

The videodisk technology devel- 
oped by Jack Wennberg and col- 
leagues is a good example of how this 
kind of information can be provided, 
but it is only the tip of the iceberg. 
The Internet will create a situation in 
which patients will be able to rapidly 
look up medical information about 
providers and procedures. I believe 
that the more explicit this process is 
made, the more difficult it will be for 
insurance companies or plan adminis- 
trators to interfere with the process. 
To the extent that a well-informed 
joint decision is made, the patient and 
the physician are true allies. 

We will see regulations to protect 
this right, but I believe it is equally 
important for the health professional 
to exercise it in a forceful way. 
Moreover, the paradigm extends 
beyond individual physicians and 
patients. Both the quality of care and 
the range of services provided in the 
health care network should be con- 
stantiy reviewed by formahzed com- 



mittees of patients and providers. 
Physicians must share with patients 
the prerogative to assess physician per- 
formance and that of their organiza- 
tion with patients. Employers ought to 
be encouraged to insist that plans vwth 
whom they contract establish such 
patient/provider quality assessment 
panels. 

Ultimately, such discussions 
between providers and patients are the 
best way to define a range of provider 
benefits to the satisfaction of all. 
Moreover, Wennberg's data suggest 
that, with few exceptions, patients have 
generally been more conservative than 
their physicians, opting for less aggres- 
sive therapies and fewer procedures. 

In a non-fee-for-service environ- 
ment, well informed decision-making 
by individual patients and groups of 
patients is likely to produce a similar 
result. The solution to the use of so 
many resources at the end of life is a 
well-informed process by which the 
clinical benefits, economic costs and 
potential discomforts are carefully 
assessed by patients and physicians. I 
expect that many patients and their 
families, when fully informed, will be 



Tourrette's syndrome, she felt 
inadequate as a parent, and 
had difficulty tolerating her 
children's pain. As a profes- 
sional one is taught to draw a 
boundary between one's self 
and one's patient, but there is 
"no boundary between the suf- 
ferer and the suffering as a 
mother." 

In his presentation, "Making 
Children Whole: Corrective 
Surgery in the Third World," 
Jonathan Jacobs '71, associate 
professor of plastic and recon- 
structive surgery at Eastern 
Virginia Medical School, and 
president-elect of the American 
Society of Maxillofacial 
Surgeons, described how he 
spends much of his time 



abroad, performing plastic 
suiifery in countries where cer- 
tain facial deformities are most 
common. Much of his time has 
been spent in the Philippines 
where 1 out of every 250 chil- 
dren has cleft palate and lip. 
Jacobs said that social stigmas 
often accompany such cos- 
metic problems, and therefore 
there are great rewards in cor- 
recting them. He also has done 
similar work in Israel, El 
Salvador and China. 

Jesse Sigelman '71, an 
associate clinical professor 
of ophthalmology at Cornell 
University Medical College, 
opened his talk, "From 
Shattuck Street to Wall Street: 
A Practical Guide," by saying 



that he was "delighted to be 
invited to speak here, rather 
than banished," referring to 
his new position on Wall 
Street. Sigelman held the 
attention of his classmates as 
he gave them unequivocal 
advice on "how to make a 
buck." 

Sigelman became an investor 
at Shufro, Rose and Ehrman in 
New York City, as what started 
as a hobby became an obses- 
sion. He stuck closely to med- 
ical metaphors: comparing 
individual stocks to petrie 
dishes — one waits to see which 
ones will grow. He spoke of 
balance sheets as genomes 
and described the stock mar- 
ket as a "guess by many, many 



people." Nor did he beat 
around the bush on the subject 
of mutual funds, which he said 
are a "sham that accomplish 
nothing." 

"Don't try to predict the direc- 
tion of the stock market," he 
warned his audience, "and 
don't do stock picking your- 
selves." The latter requires too 
much time and concentration 
from doctors. And Sigelman 
called for introspection, 
"Evaluate your own personality 
before you evaluate stocks," 
he advised. 

Sarah Jane Nelson 



30 



Harvard Medical Alumni Bulletin 



far less aggressive than they have been 
in the past. Having these kinds of joint 
discussions allows one to understand 
how individual patients and groups of 
patients value procedures, interven- 
tions and personnel, and will allow far 
more flexibiHty for the health care 
team. It will also reduce health care 
expenditures. 

But this kind of alliance should not 
stop with managed care organizations 
caring for the middle class. Health 
care providers and patient advocates 
should work at community, metropoli- 
tan and state levels to establish 
provider/consumer panels to assess the 
quality of care in their communities. 
Regardless of the overall outcome of 
the Oregon experiment, it clearly 
began a process by which citizens and 
providers began a dialogue to put 
some limits on health care. 

These panels can generate data and 
political will by not only looking 
closely at Medicaid management, but 
also at care for the uninsured and 
those in public facilities. In the case of 
Hawaii and Tennessee, important 
progress has been made in coverage 



for all citizens. Under Howard Dean's 
leadership in Vermont, coverage for all 
children up to age 1 8 has been accom- 
plished largely through an incremental 
cigarette tax. 

The next major emphasis in federal 
government ought to be a requirement 
to extend health coverage for all 
youngsters up to age i8. The logic of 
this approach is compelling. Most seri- 
ously ill youngsters are cared for under 
an entitlement program, and thus pro- 
viding health care for all youngsters is 
relatively inexpensive. This is the kind 
of incrementalism that ought to con- 
tinue at the state level, but also should 
be emphasized at the federal level. 

In the absence of a radical federal 
organization of health care in the 
United States, I believe we should 
focus on three areas: 

• free exchange of information about 
the nature of care and the use of that 
information by informed physicians 
and patients in making personal deci- 
sions, decisions about health care plans 
and decisions for their community; 



• identify ways in which one can 
incrementally increase health care 
coverage; and 

• monitor quality of health and 
health care at the state and federal 
level. 

Patients and their families should 
be enlisted as partners in all three of 
these activities. If efforts take place in 
multiple states, they will ultimately 
force federal action. 

The real question is whether 
providers and patients can form the 
kind of meaningful alliances that will 
assure that the outcome of that regula- 
tory environment is productive and 
useful. I am optimistic that can happen 
because I believe that Winston 
Churchill was correct when he said 
that Americans always do the right 
thing — after they've tried everything 
else. ^ 

Kenneth I. Shine '6i is president of the 
Institute of Medicine of the National 
Academy of Sciences. 



Members of the Class of 
'86 catch up. 




Autumn 1996 



31 



Sacred Principles 



hy Nina E. Tolkojf-Rubin 



New paradigms 
must remain 
true to the 
traditions 



Friends and colleagues, grateful 
children of HMS, I bid you welcome as 
we return to the Quadrangle today for 
knowledge, fellowship and guidance. 
We come together at a time of great 
turmoil. Never in medical history has 
there been such a rich array of oppor- 
tunities for preventing and treating 



human disease; and never in medical 
history has there been such an array of 
challenges that threaten to change the 
way we learn, teach and practice medi- 
cine. On the one hand, the miracles of 
modern biology provide us with 
imprecedented tools to assuage human 
suffering. On the other hand, the 
remarkable successes of twentieth-cen- 
tury medicine have sown seeds of our 
present economic dilemma. 

Health care costs in the United 
States are now approaching $i trillion, 
consuming 1 5 percent of the gross 
national product. This far outstrips the 
proportion spent by any other country. 
And despite this, we still have not pro- 
vided basic health care coverage to all 
our citizens. Moreover, there is no 
clear demonstration — as measured by 




national health indices — that this capi- 
tal investment is associated with better 
health than achieved in countries 
where less monies are expended. 

With the failure of the Clinton 
health care initiative, the spiralling 
costs of health care have led employers 
and insurers to develop programs of 
managed care, in which cost contain- 
ment incentives are built into the med- 
ical system. These managed care 
initiatives have evolved from simple 
price discounts, to strict forms of 
resource utilization management, to a 
system of capitated payments, which 
place providers at financial risk for the 
care of enrolled populations. 

There is no question that economic 
pressures and incentives are changing 
care practices. Integrated delivery sys- 



James Sabin '64 and Nina 
E. Tolkoff-Rubin '68 



tems are emerging that impact the aca- 
demic medical center and community 
hospital alike and are changing the 
relationship between primary care 
physicians and subspecialists. Many 
commentators have stated that nothing 
less than a reinvention of medicine and 
medical practice are necessary to deal 
with these new economic realities. 

In times of upheaval, one of the 
important lessons that we were taught 
within these walls was that we should 
return to basic principles and then, on 
these cornerstones, build new struc- 
tures of thought and practice that deal 
with the new reahties. We are at one 
of those critical junctures. We clearly 
must respond to the economic impera- 
tives — the changing needs and expec- 
tations of our patients and society. We 
must heed the wake-up call. At the 
same time, we must remain true to our 
core values. If we give them up, we 
give up what is most precious about 
who we are — our professional trust. 

Nearly 30 years ago, my classmates 
and I stood here and in one of the 
landmark events of my life, swore to 
adhere to the teachings of 
Hippocrates: "I will look upon him 
who shall have taught me this art even 
as one of my parents... With purity 
and with holiness I will pass my Hfe 
and practice my art. . . Into whatever 
houses I enter I will go into them for 
the benefit of the sick and will abstain 
from every voluntary act of mischief 
and corruption." 

At the same time we swore to 
uphold this oath, we took note of a 
cardinal teaching of Hippocrates: "And 
if there be an opportunity of serving 
one who is a stranger in financial 
straits, give full assistance to all such. 
For where there is love of man there is 
also love of the healing art." 

Hippocrates walked in the steps of 
Aesculapius, the first Greek physician. 
Fact or fancy, god or man, the spirit of 
Aesculapius continues to be celebrated 
and honored at this institution. 

Statues of Aesculapius show him to 
be a tall, handsome young man, 
clothed in a long robe. In his hand he 



holds a staff with a coiled snake. In 
ancient Greece serpents were thought 
to represent life, wisdom and healing. 
The caduceus has become the symbol 
of the medical professon. 

Legend has it that Aesculapius, son 
of Apollo, was a skilled and "gentle 
physician" known for his diagnostic 
acumen. He was raised by the centaur 
Cheiron, who taught him the secrets 
of healing and medicine. Temples 
were built to worship Aesculapius, and 
here the sick came seeking relief from 
their pain and suffering. These tem- 
ples offered programs of rest ("temple 
sleep"), emotional support, proper 
diet, exercise and physical therapy — 
truly the beginnings of modern 
patient-focused care, disease preven- 
tion and health promotion, as Talbott 
notes in A Biographical Histoij of 
Medicine (Grune & Stratton, 1970). 

Aesculapius sired four children. His 
two daughters, Hygeia and Panacea, 
became the patronesses of public 
health and therapeutics (Our first 
female role models?); his two sons, 
Podelirius and Machaon, also were 
physicians and became the prototypes 
for internist and surgeon, respectively. 
One treated by diet and herbs; the 
other was agile with his hands. 

To these beginnings, Hippocrates 
and his colleagues added the study of 
pathophysiology. "Sickness has a phys- 
ical basis. If we can find the cause, we 
can cure the disease." Herein lies the 
cornerstone of modern medicine: a 
system based upon a reverence for 
learning and teaching, the placement 
of the patient first before financial 
considerations, and the recognition as 
Peabody put it so well — "that the care 
of the patient means caring for the 
patient." These are the principles that 
must be maintained in any new para- 
digm of medical care. 

And clearly our principles are being 
tested in the new managed care envi- 
ronment! I pose these questions: 

• How can we assure the quality of 
patient care as we vigorously strive 
towards cost containment? 



• How can we preserve the three 
components of our mission — patient 
care, teaching and research — at a time 
when there are economic pressures to 
cut reimbursement from both the pub- 
lic and private sectors? 

• How will the traditional role of the 
physician as patient advocate be 
assured in a capitated environment in 
which the physician may be rewarded 
for restricting the use of services and 
limiting access to care? 

Medical care is not a commodity. 
As Jerome Kassirer, editor of the New 
England Joiii~nal of Medicine, observes: 
"Market-driven health care creates 
conflicts that threaten our profession- 
alism." It strikes at the heart of the 
doctor/patient relationship. 
"Increasingly physicians may be forced 
to choose between the best interests of 
their patients and their own economic 
survival." We must not let this happen 
or we will lose the public trust. 

We, loyal sons and daughters of 
HMS, may be considered among the 
most fortunate of the medical profes- 
sion. We have been educated by lead- 
ers in every field of science and 
medicine, provided easy access to 
opportunities and the corridors of 
power, and assured that our ideas and 
thoughts will receive appropriate con- 
sideration. Harvard Medical School 
and her graduates have played a major 
role for many decades in dealing with 
challenges and developing new initia- 
tives. Never has continuation of this 
tradition been more important. 

If we are to remain true to the tra- 
ditions and admonitions of 
Aesculapius, Hippocrates and our own 
teachers — Cliff Barger, Bernie Davis, 
Alex Leaf, Dan Federman, Roman 
DeSanctis and so many more — then 
we have the responsiblility to develop 
new paradigms that maintain our 
sacred principles and yet pay appropri- 
ate attention to economic reality. 
Chaos and crisis, although unsettling 
to say the least, provide opportunity, 
and HMS and her graduates have never 



Autumn 1996 



33 



shirked either responsibility or oppor- 
txmity. We are living in "interesting 
times"; whether this will be a curse or 
a blessing is in our hands. 

\Miat then are we to do? First and 
foremost, as Jordan Cohen '60, presi- 
dent of the American Association of 
American Medical Colleges, has 
stated, we must have a shared vision of 
who we are and what we want to be as 
we confront the "brave new world." 
And then we must take action. 

Traditionally, the most gifted med- 
ical scientists and physicians have 
restricted their efforts to individual 
patient care, their laboratories and to 
education. With some notable excep- 
tions, we have left politics to the 
politicians, economics to the econo- 
Stephanie Pincus '68 yields the presidential gavel to Suzanne 



mists, and health care management to 
the managers. We, and the public, can 
no longer afford this variant of tunnel 
vision. Practicing physicians must take 
on a leadership role to assure that 
patient rights, quality of care and med- 
ical decision-making remain true to 
the basic principles that make up our 
birthright. 

To enable us to seize the reins of 
public leadership, HMS must do two 
things: prepare the present and future 
generation of HMS students for this 
function, and establish an alumni cur- 
riculum as a serious educational effort 
so that those of us now in a position to 
lead can be trained to be maximally 
effective in this new arena. 

We must develop professionally 

Fletcher '66. 




dominated oversight initiatives to pro- 
tect patients from overzealous capi- 
tated managed care programs. If we 
don't take on this responsibiUty as a 
profession, then it will be done to us! 

Financial reward systems need to 
be developed in which no doctor is 
rewarded for withholding care, no 
patient is refused access because they 
are high risk. Instead, pools need to be 
established so that economies of scale 
are achieved and the individual doc- 
tor/patient relationship is protected. 
Legislation is needed, and we should 
take a significant role in designing and 
lobbying for this legislation, demand- 
ing that all aspects of the health care 
industry share equally in the costs of 
the desperately ill, the poor and the 
uninsured. No one segment of the 
medical system can afford to shoulder 
this burden alone. 

Clinical research, particularly trans- 
lational research, in which the discov- 
eries of the bench are brought to the 
bedside, deserves a new investment. 
Harvard Medical School must take a 
leadership role here, both in the edu- 
cation of investigators and in design- 
ing and implementing programs that 
raise monies to support these efforts. 

Finally, HMS is medical education. 
In the rush to economically driven 
medical care, the traditional emphasis 
on education that has made this the 
leading center for medicine in the 
world is being threatened. We must 
renew our efforts to preserve educa- 
tion. And just as the school has pio- 
neered changes in the preclinical 
curriculum and brought new 
approaches to learning — we must 
bring the same creative energies to 
launch New Pathways in the clinical 
years. 

As medical practice moves from the 
inpatient to outpatient arena, from the 
acute care hospital to the community 
setting, we must give our future physi- 
cians not only the intellectual and ethi- 
cal framework, but the tools to take a 
leadership position in the new envi- 
ronment. Harvard Medical School 
should not only lead in preserving 



34 



Harvard Medical Alumni Bulletin 



medical education, but develop new 
ways to accomplish it. New course 
material and teaching approaches 
using telecommunications, computers 
and the "virtual human" are necessary, 
though will require increased invest- 
ment. Harvard Medical School and 
her graduates are a national and inter- 
national resource, and preservation of 
her principles and her products 
deserve support. 

I stand before you a proud daughter 
of HMS. In a sense I have never truly 
graduated. I have been privileged to be 
taught by the greatest practitioners of 
the art and science of medicine in the 
world. I met my husband, also an HMS 
graduate, at MGH. I have been privi- 
leged to serve as an officer of the 
Alumni Association and to teach stu- 
dents, house officers and fellows alike. 

As one reviews the writings and 
teaching of Aesculapius, Hippocrates, 
Barger, Davis, Leaf and others, I am 
impressed with not only the intellec- 
tual power but the moral power of 
these teachings. We, the heirs of our 
teachers, cannot forget these lessons 
and, as we confront the new realities, 
must remain observant to the time- 
honored truths. Otherwise, what will 
we tell our children? ^ 

Nina E. Tolkojf-Rubin '68 is HMS associ- 
ate professor of medicine and director of 
hemodialysis and CAPD units at 
Massachusetts General Hospital. 



Protecting 
Our Empathy 



by Joshua M. Hauser 

The difficulty 
of maintaining 
values learned 
in medical 
school 



Despite asking me several months 
ago if I could speak today. Dean 
Federman was able to predict that I 
would be on call last night. And so I 
am grateful for the opportunity to turn 
off my beeper for a couple of hours 
and see firsthand a sunny day after a 
night on call. In the brief time I have 
here, I want to do three things. First, I 
want to talk about how my medical 
student experience prepared me for 
some of the issues I've faced as an 
intern. Second, I'd like to discuss how 
I see these issues differentiy as an 
intern than as a student. And finally, I 
want to think out loud about some 
specific pressures that threaten our 
empathy as new doctors. My remarks 
are not specifically addressed toward 
the issue of managed care, but I hope 
that they contain lessons for patient 
care, managed or not. 

Eleven months after beginning my 
internship, I have realized that if there 



is one specific thing that prepares you 
for being an intern, I missed it. I 
remember wondering last year at 
around this time, as I sat in those seats 
I'm looking at now, what the secret 
was to being a good intern. And soon 
after graduation I went across the 
street to the Coop, looked around, and 
came back with a few packets of index 
cards, some books I hoped would fit 
into my white coat pocket, and some 
extra earpieces for my stethoscope. 
Standing here in 1996, 1 realize that 
those things are nice to have in a pinch 
but they don't do the trick. 

While I couldn't find one secret to 
preparing to be an intern, there are 
many hints and pieces of my experi- 
ence at HMS that did prepare me. From 
the start of medical school, the ideal of 
collaboration with colleagues plays 
itself out in our tutorials, our lab ses- 
sions and even in hanging around the 
medical education center. Our strug- 
gles in the first years of medical school 
frequently took the form of "How 
much do I need to study?" or "Where 
do I find the answers?" or "How much 
of the brachial plexus do I really need 
to memorize?" 

These are questions we asked over 
and over of ourselves and our class- 
mates and, often in vain, of our teach- 
ers. I say "in vain" not because they 
ignored us (which, I assure you, they 
only rarely did), but because they val- 
ued and encouraged collaboration 
among ourselves in searching for 
answers. And after we got over the ini- 



AuTUMN I 996 



35 



rial frustration of die professor not 
telling us answers, we seemed to man- 
age and often did learn things from 
each other. 

As an intern, the parallels are 
inescapable. We rely on colleagues at 
all levels for advice, guidance, confir- 
mation of our good ideas and redirec- 
tion of our missteps. The questions are 
different: "How much do I study?" has 
become "What's the best way to work 
up this problem?" "Where do I find 
the answers?" has turned into "Is there 
Paperchase on this terminal?" But the 
route to the solutions is very much the 
same. In a world with so many choices 
of how to approach a problem and 
even more ways to treat a disease, this 



collaborative model becomes a neces- 
sity, both for learning and for patient 
care. 

It is not just intellectual support 
and collaboration that is crucial. We 
also rely on each other for support 
during hard times, especially when 
things are going poorly. The flip side 
of the fact that outpatient care is flour- 
ishing is that now you have to be 
sicker to be admitted to the hospital. 
This means that the chance of things 
not going well is that much greater. 
More crucial than support from 
friends and classmates when an exam 
didn't go well has become support 
from friends and colleagues when a 
patient isn't doing well. 



The second way that HMS prepared 
me for internship was by encouraging 
an openness to new experiences. This 
was something of a necessity in a sys- 
tem where you rotate li-om month to 
month to very different hospitals and 
clinical services. The range of styles 
and personalities in this community is 
vast: I sometimes wondered how some 
of the surgeons I met at the Brigham 
would feel at a dinner with some of the 
psychiatrists I worked with at 
Cambridge Hospital. But imagining 
dinner parties isn't the only form this 
takes. New academic and community 
experiences abound at HMS and would 
take the rest of the morning to discuss. 

The most important new experi- 



The audience takes a tum to talk. 




36 



Harvard Medical Alumni Bulletin 



ences we face, however, are those of 
our patients. At HMS, the patient/doc- 
tor course and in a more sustained 
way, our clinical rotations, impressed 
upon us the need to open ourselves to 
the lives of our patients. This was 
more than just listening in order to 
find the diagnosis; it was trying to con- 
nect with another person. At times, 
these patients were from different cul- 
tural or social backgrounds. At times, 
they were from different neighbor- 
hoods in Boston. All of the patients we 
saw then and see now, however, share 
one very basic difference from us: they 
are ill and we are, by and large, well. 
This may sound like an obvious point, 
but it is one worth emphasizing. 

This openness to new experiences 
is more elusive in residency. With the 
sheer volume of new tasks we now 
face, connecting with others becomes 
that much more difficult. In medical 
school, we were taught to listen to 
patients, to ask open-ended questions, 
and to understand how patients' ill- 
nesses affected the rest of their lives. 
These were broadly called "psychoso- 
cial issues," while in residency they are 
the "touchy-feely" aspects of medicine. 
We quickly discover that things are 
turned on their head now. Listening 
too hard takes too much time, open- 
ended questions lead to too many tan- 
gents, and the effect of illness on the 
rest of the patient's fife becomes a 
"placement issue" for which we have 
case managers. 

The third way that HMS prepared 
me for residency and beyond was 
through a number of role models and 
mentors I encountered along the way. 
These have been teachers in classes, 
colleagues in research, and people 
whom I bumped into in the hallway. I 
have been explicidy and implicitiy 
encouraged to pursue my interests in 
medical ethics and patient/doctor rela- 
tions. 

In internship, role models and 
teachers are much closer in age and 
position to us. They are residents and 
fellows who teach us not from per- 
spective of many years devoted to a 



research question or a panel of 
patients, but from the experience of 
just having been where we are now. 
These are different sorts of role mod- 
els and equally valuable ones. 

When I was a third-year medical 
student, I saw a patient in my surgery 
rotation who made a tremendous 
impression on me and spawned much 
of my current interest in end-of-life 
care. The case involved a woman in 
her 60s who came to the hospital for 
the repair of a hiatal hernia. She had 
been healthy all her life and this opera- 
tion was to delay her start of summer 
gardening, but nothing more. In the 
operating room, it was discovered that 
she had, to the surprise of everyone 
around the table, ovarian cancer 
spread throughout her abdomen. 

After the operation, I remember 
the discomfort of everyone on the 
team when it was time to talk with her. 
This went on for days. Suddenly, this 
healthy woman who had come to the 
hospital for a relatively minor proce- 
dure was now a patient with a disease 
that would likely end her life. I also 
remember my own discomfort in talk- 
ing with her and with the doctors on 
the surgical team, and I wondered if 
there was any way we as students and 
doctors could learn more about being 
with and talking to patients near the 
end of their lives. 

After that third rotation I worked at 
the Division of Medical Ethics on a 
video and a course about care near the 
end of life for medical students, and at 
the Brigham analyzing advance direc- 
tives — living wills and health care 
proxies. Each of these projects 
involved the work of many faculty and 
student collaborators with whom I 
explored what still feel like very new 
and complex ideas. The patients who 
triggered these interests in me and 
who form the core of our course are 
perhaps the most valuable collabora- 
tors. 

These three aspects of my develop- 
ment at HMS — the value of collabora- 
tion, the openness to new experiences 
and the input of a number of men- 



tors — prepared me well for internship 
and beyond. Many specific values and 
principles come within these pieces, 
but today I wanted to highlight the 
more general ways I've learned. 
Principles such as an unstinting 
respect for patient autonomy, the 
preservation of informed consent, and 
a devotion to ensuring equal access to 
care must all come within these ways 
of learning and practice. 

How do I see things now as an 
intern? For one, I've tried to maintain 
the values and connections that I've 
just discussed. But I also see (often all 
the more vividly after a night on call) 
how pressures of time can make us 
tired, discouraged and even angry. I 
see how the volume of work exposes us 
to many different lives and illnesses 
but also overwhelms us. Eleven 
months after beginning internship, I 
know that my colleagues and I are try- 
ing to preserve the ideals we began 
with, but I will be candid and say that 
it can be very difficult. 

I don't think it's an oversimplifica- 
tion to say that compassion and empa- 
thy require time and concentration. 
No matter how much we fight against 
it, it's much harder to muster the com- 
passion that we should have at mid- 
night than earlier in the day. And yet, 
it is probably the patient scared and in 
pain at midnight who needs our com- 
passion more than the elective admis- 
sion at noon. 

It is much harder to take the time 
to listen to and understand a patient 
whose language is clouded by demen- 
tia, delirium or alcohol than one who 
gives a clear history. Perhaps reflecting 
our own frustration, we often refer to 
these patients collectively as "poor his- 
torians." And yet, it is probably these 
patients who feel lost or confused by 
their disease who most need our time 
and understanding. 

But one of internship's first and 
lasting lessons is that our time is short 
and our goal is efficiency. And in many 
ways, this stands us in good stead; in 
some, it doesn't. One measure of a sea- 
soned intern is how short the "social 



Autumn i 996 



37 



histon'" is for each patient. If we're 
really good, it's just four words, a few 
semicolons and some numbers: "ciga- 
rettes: 50 pack years," "alcohol: 2 a 
week" and "other drugs: none." The 
family history isn't even words, it's let- 
ters: CA, CAD, NIDDM. I Stepped outside 
the bounds the other day when I asked 
a 94-year-old patient about her family 
and got a whole new set of numbers 
and words: 6 children, 22 grandchil- 
dren and 26 great-grandchildren. 
These numbers, it turned out, were 
much more important than the num- 
ber of cigarettes she had smoked many 
years ago. 

As residents and physicians, we 
must continue to step outside the 
bounds and ask about those things in a 
patient's life that are not so obviously 
connected with their illness. Often, I 
suspect, we will find that the links are 
not so obscure. I recently admitted a 
patient whose alcohol use led him to 
drive while intoxicated, causing him to 
crash his car. This led him to the 
emergency room and on to the operat- 
ing room for the evacuation of a sub- 
dural hematoma. The real question, 
however, is why he began to drink 
alcohol in the first place. But when he 
comes in at i :oo AM and gets a lumbar 
puncture, and he needs his sleep and 
you need yours, that's a hard question 
to ask, let alone answer. 

It is hard as an intern to explore all 
these pieces of illness while we are jug- 
gling other tasks. In medical school, 
we had a few patients at a time and 
hours to talk. As interns and residents, 
we have more patients, less time and 
endless lab values, x-rays and discharge 
summaries to keep track of. But even 
as interns, I think we can ask some of 
these questions of our patients. 

How often, for instance, do we 
know the latest potassium value com- 
pared to knowing patients' occupations 
or who they come home to at night? 
I'm not trying to advocate that we 
neglect the careful attention to acute 
medical issues that patients require, 
but that we also try to make room for 
the other things. Far too often, the 



opportunity to take time with a patient 
that was a privilege as a student threat- 
ens to become a burden as a resident. 

I saw a woman in her 60s recently 
who was admitted for chest pain. She 
had had multiple admissions to the 
hospital and trips to the emergency 
room for chest pain, and a coronary 
artery bypass a number of years before. 
On the first night, we asked her all 
about her symptoms, her previous hos- 
pitalizations and, of course, about ciga- 
rettes. She had some chest pain that 
night. Her EKG was fine and the nitro 
under her tongue worked wonders, but 
she sure looked scared. The next 
morning she told us that she felt tired 
and dizzy and didn't even feel like get- 
ting out of bed. She said she often felt 
this way at home. Her blood pressure 
was fine. Her pulse was regular. We 
were "rounding" so we moved on to 
the next patient. 

Later in the day, a fellow resident 
and I went back to talk with her. She 
looked scared and sad. We asked her 
how she was and at first she said okay. 
Then we asked her how things were at 
home and she began to cry. She told us 
how she lived with her sister who 
ignored her, even though she was 
completely dependent on her for 
shopping, for getting her medicines, 
and most, importantly, for companion- 
ship. She hadn't seen any of her other 
family members for months. She 
hadn't slept through the night for 
years and hadn't been able to concen- 
trate or paint like she used to. We 
talked with her for a while about how 
we might help her because we began 
to realize that her chest pain was no 
longer her major problem; it was more 
likely her depression. 

This all came out not because of a 
subtle physical exam finding or test, 
but because we allowed ourselves to 
ask questions and for whatever reason, 
she felt able to confide in us. The next 
morning, her chest pain was gone. I 
don't think we had gone too far in 
helping her depression, but at least we 
had begun. We had done so simply by 
using what are persistently scarce 



resources in a very rich hospital: time 
and attention. 

Just as time and fatigue can 
threaten our empathy toward patients, 
our own language can also be damag- 
ing. I want to end this talk by reflect- 
ing on some of the language that we 
use when we talk about patients. If we 
listen to how we talk, I think we can 
learn a lot about how we act towards 
patients. 

I've been continually struck this 
year by what we as residents do to 
patients. I choose the word "do" inten- 
tionally. While, in a larger and very 
important sense, we try to "cure" and 
"help" those who come onto our ward, 
our daily rounds are composed of 
much more mundane battles. Again I 
say "battles" on purpose. Many of you 
probably remember talking about the 
drugs we "have in our armamentar- 
ium." The drugs may be different now, 
but the expression remains. The old 
expression "war on cancer" and newer 
"war on AIDS" reflect this too. 

What kinds of battles do we as 
medical residents tmdertake? A few 
scenarios. When we want to diurese a 
patient, we "hit him with some lasix." 
When a patient's blood pressure is a 
bit high or his angina keeps coming, 
we "slap a little paste" on him to give 
him nitroglycerin ointment. The 
patient in respiratory distress gets 
"gassed" and if things don't turn 
around he gets "tubed" when he needs 
to be intubated to support his breath- 
ing. 

On one level, these expressions are 
trivial shorthand adopted to make our 
communication easier. But I think they 
contain more than that. In a climate 
where we constantly face diseases out 
of our control, I think these expres- 
sions reflect some attempt to get a 
handle on things that we can control. 
It's too simple to say that these expres- 
sions have arisen only out of a need to 
control patients, but it is naive to deny 
that this is not partly the case. 

And what about when we have no 
control? When we can't do anything 
to stop the illness imfolding before us, 



38 



Harvard Medical Alumni Bulletin 



we sometimes say that a patient has 
"failed" treatment. We sometimes 
hear a patient whose condition is dete- 
riorating described as "trying to die." 
Again, we know these sayings are just 
shorthand for describing treatments 
that haven't worked, but I've often 
wondered why it is more common to 
say that they, the patients, have 
"failed" rather than that we, the doc- 
tors, have "failed." 

Finally, I realize that the beginning 
of my residency has reinforced what I 
learned in medical school, both in the 
need for collaboration and openness to 
the experiences of others and, even 
more basically, in the recognition that 
there is much out of our control as 
doctors and much we do not know. 
We can try to control as much as pos- 
sible and we often do — anyone who 
has spent much time in an ICU knows 
the bounds of our control are wide. 
And sometimes this is important. 

But equally important, I think, is 
that we try to connect to and learn 
from our colleagues and our patients 
in interactions that we have every day. 
This takes our attention, our time, our 
patience and a piece of ourselves. 
These are all qualities that we must 
vigilandy protect for our own sake and 
for those we care for. If we don't, I 
think we risk losing many of the rea- 
sons we went into medicine in the first 
place. ^ 

Joshua M. Hauser '5? j is a medical resi- 
dent at Brigham and Women ^s Hospital. 
He is also a member of the editorial board 
of the Harvard Medical Alumni 
Bulletin. 



The Ethics 
of Efficiency 






f 



hy James E. Sabin 



In pursuit of 
good practice in 
managed-care 
psychiatry 



I WAS FLATTERED WHEN DeAN 
Federman asked me to speak on 
Alumni Day, until he actually gave me 
my assignment. With slight embellish- 
ment, this is what he said: 

"Jim, I understand that you have 
been writing and talking about ethical 
managed care. Most of the audience 
on Alumni Day will not be very happy 
about managed care. Alums who 
believe in the tooth fairy may also 
believe there is such a thing as ethical 
managed care, but the rest will be 
pretty skeptical. So do your best, try to 
be amusing, don't cite any references 
and say something personal!" 

I have been practicing psychiatry at 
the HMO that is now called Harvard 
Pilgrim Health Care since 1975. 
Psychiatry is a perfect laboratory for 
studying the ethics of managed care 
because it depends so much on trust 
and the quality of the doctor/patient 
relationship. What I want to do now is 
put myself on the couch for a change 
and free associate about how ethical 
issues actually play out in my practice. 



Harvard Medical School taught us 
the basics of medicine. Surgeons give 
operations. Internists give pills. 
Psychiatrists give time. Let me make 
my first confession. In practice I spend 
very little time grappling with the big 
ethical issues that you might expect a 
doctor in managed care to be strug- 
gling with — issues such as balancing 
Hippocratic commitment to individual 
patients with stewardship or public 
health commitment to a population, 
achieving fairness in resource alloca- 
tion, and distinguishing between what 
people want and what they really need. 
For me, these large, "capital E" ethical 
issues tend to show up as humble, 
"small e" nitty gritty ethical issues 
about managing time! 

When I had a fee-for-service prac- 
tice, I could decide that my practice 
was full and steer new referrals else- 
where. My life at the Harvard Plan is 
different. As a member of a large 
group practice, I am responsible to the 
HMO population, not just to the mem- 
bers who are already my patients. That 
means that unless I have taken on 
more referrals than we expect our doc- 
tors to handle, my practice is never 
closed. 

When I meet patients for the first 
time, they are often suspicious — occa- 
sionally because they are paranoid, but 
more commonly because they read 
what journalists and cartoonists say 
about managed care. Twenty-one 
years ago, when I started to practice at 
the Harvard Plan, patients were suspi- 



AuTUMN 1996 



39 



cious because they heard that HMO 
psychiatrists favored short-term treat- 
ment. They worried that I might sug- 
gest brief treatment when they really 
needed to be seen for a long time, or 
that I might recommend outpatient 
care when they needed to be in the 
hospital. 

In 1996 the suspicions are more 
extensive. Patients have read about 
investors who earn more by paying 
doctors to do less and about gag rules 
designed to keep patients in the dark. 
Today's suspicious patients don't just 
fear the HMO's clinical approach — they 
worry about the doctor's motives as 
well. 

So picture the situation when I 
meet a patient for the first time. The 
patient may be worried about the 
treatment I will offer and my motives 
for offering it. At the same time I am 
aware of the need to keep myself avail- 
able for patients whom I haven't even 
met yet. These first meetings between 
semidistrustful patients and a possibly 
self-protective psychiatrist sound like a 
recipe for disaster. 

I learned a key lesson about the 

John Appel '36 




doctor/patient relationship in managed 
care from one of my first patients at 
the Harvard Plan, who was on a ram- 
page against the HMO when I first met 
him. "This HMO is trying to get me to 
see a social worker and get me out as 
fast as possible! I need long-term ther- 
apy and I need a doctor! What's going 
on here?" 

I am happy to tell this group that 
HMS tradition came to my rescue. We 
were taught — and not just in psychia- 
try — to go into difficult situations 
more deeply, not to run from them. So 
I did what our clinical mentors at HMS 
taught us to do. I simply asked the 
irate HMO member to help me under- 
stand exactly what he felt he needed 
and sat back to listen. 

The answer was quite illuminating. 
The member, who became my patient, 
told me he thought he might have 
depression and definitely had what he 
called a "nudgey personality." He 
wanted to see a doctor because he 
thought he might need medication. 
And he wanted long-term treatment 
because he thought — quite correctly — 
that the condition was chronic. 

Because the doctors in the Harvard 
Plan group practice take responsibility 
for the HMO population as well as our 
individual patients, we don't place 
arbitrary limits, such as requiring 
short-term treatment, on our practice. 
This made it easy for me to agree with 
my patient that the treatment would 
have no time limit. 

But what about the intensity of 
therapy? My patient glared at me and 
said it should certainly be no less than 
once a week for an hour. I acknowl- 
edged that in the fee-for-service com- 
munity once a week therapy would be 
the norm and that there was certainly 
no contraindication to that schedule. 
But I explained our group's commit- 
ment to using time as efficiently as we 
could in order to be available to all 
members and to keep the cost of the 
program down. I suggested that we 
meet a couple of times soon to under- 
stand more about his needs, but I pre- 
dicted that once we had a plan we 



could probably conduct the treatment 
with fewer meetings. Was he willing 
to give it a try? 

He was. Twenty years later we still 
see each other, generally every two to 
three months for a half an hour. He is 
well past retirement age. His depres- 
sion recurs and the "nudgey personal- 
ity" is still there, but he handles both 
conditions with aplomb. 

I apply what this man taught me 
every day in practice. When I meet 
new patients I am determined to 
understand their model of what needs 
to be done to set things right. I hope 
they are not going to say "five times a 
week psychoanalysis" or "long-term 
hospital care at McLean" because I 
know that I won't be offering those 
treatments. But we have to start out 
with our cards on the table, even if 
that means dealing with disagreement 
and disappointment. Once we get to 
this basis of mutually understanding 
the facts, we can generally use our 
ingenuity to make a mutually satisfac- 
tory plan. 

Here is another confession: When I 
got a wristwatch that gives the date as 
well as the time, I fell into a new prac- 
tice. When my patients and I were fac- 
ing a major problem that had no 
definitive solution, I would often find 
myself rather ostentatiously looking at 
my watch. This is bad manners, and 
certainly can raise the patient's anxiety 
about time and my commitment to the 
treatment. 

But what came out of my mouth 
wasn't about the hour, but the calen- 
dar. In a circumstance like the one we 
are in here I would say something like, 
"If we happen to be meeting on 
Alumni Day on Friday, June 7, 2001, 
my guess is that we will look back and 
say that we were just beginning to 
understand the ethics of population- 
based practice and honesty about 
resource limits in 1996." 

With hindsight I understand what I 
am doing with the watch. Looking at it 
so ostentatiously invokes the finitude 
of the precious time the patient and I 
have together. In my population-based 



40 



Harvard Medical Alumni Bulletin 



HMO practice I am always striving to 
accomplish objectives with the least 
expenditure of time. But by using the 
watch to imagine a future in which my 
patient and I are together looking back 
at the present moment, I am present- 
ing an image of ongoing collaboration 
and solidarity, within which we can 
address the uncertainties of the illness 
despite our recognition of resource 
limits. 

Twenty-one years of practice at the 
Harvard Plan convince me that doc- 
tors and patients can join together 
openly and honestiy to meet the chal- 
lenge of managing individual care in 
the context of limited resources. This 
may soimd like one of Pollyanna's fan- 
tasies, but when I started HMS in 1 960, 
most doctors still believed it was cruel 
and destructive to tell the truth to 
patients with cancer. Medical students 
were taught that telling the truth 
would inevitably destroy our patients' 
hope and their capacity to trust us. 

In i960 that hypothesis was pre- 
sented as an incontrovertible fact. In 
1996 we know it was wrong, and med- 
ical students learn how to join with 
patients in confronting hmits at the 
end of life. Done skillfully, this 
improves care and deepens trust. 

If we doctors have learned how to 
join with our patients in an ethical 
manner to face the end of life itself, we 
can certainly learn to join with our 
patients in an ethical manner to face 
and manage the disappointments 
imposed by resoiu-ce limits. 

Everything I have learned first 
hand about the ethics of managed care, 
however, has been learned in a not- 
for-profit group practice. While I am 
deeply committed to the kind of popu- 
lation-based group practice that I have 
been privileged to be part of for 2 1 
years, I am deeply uncomfortable with 
the rapid emergence of large, investor- 
owned health systems. I fi-ankly have 
no sense of how I would handle the 
idea of constraining care to produce 
dividends for the owners in my rela- 
tionship with patients and I hope I 
never have to do it. 



However, HMS taught us to be 
empiricists, and as much as the idea of 
investor-owned health care systems 
goes against my understanding of a 
viable context for ethical health care, I 
have to recognize that my reaction is a 
hypothesis. Maybe there is a for-profit 
model that will work for health care — 
perhaps derived from our experience 
with regulated utilities, which are 
allowed to make a profit but only 
under stringent conditions designed to 
protect and promote the public good. 

The last time I saw former-Dean 
Robert Ebert was in December, just a 
month before he died. I was presenting 
a proposal for a center for ethics in 
managed care, to be joindy sponsored 
by the Division of Medical Ethics at 
HMS and the Department of 
Ambulatory Care and Prevention, 
which is based at Harvard Pilgrim 
Health Care. Dr. Ebert loved the idea 
and hoped he would live long enough 
to help us bring it into existence. He 
reminded me that when he launched 
the idea of the Harvard Plan 30 years 
ago, he pictured an entity that would 



Professor of Anatomy Erick Erickson, Carleen Zawacki and Bruce Zawacki '61 

r 



help the country explore what it meant 
to practice good medicine and good 
ethics in a setting that recognized that 
while our resources are extensive, they 
are limited. 

His illness prevented us from learn- 
ing more from him, but we were pro- 
foundly grateful for his blessing. I like 
to imagine that when my colleagues 
and I join with our fellow HMO mem- 
bers to pursue his vision of good prac- 
tice and good ethics, he is looking over 
our shoulders wearing his patented 
bow tie and smiling. ^ 

James E. Sabin '6^ is HMS associate clini- 
cal professor of psychiatry and associate 
director for the teaching progi'am at 
Harvard Pilgrim Health Care. 




Autumn 1996 



41 





Reunion Reports 



42 



Harvard Medical Alumni Bulletin 



62ND 




The Class of 1934, while having 
only 2 8 survivors, experienced a warm 
and charming 62nd reunion. Starting 



with the symposia, a brief two-day 
program was planned with a dinner 
Thursday night in the deanery of 



Vanderbilt Hall — a suggestion made 
by Nora Nercessian. Since we had 
been denied access to this sanctuary 
during our four years, it seemed a 
sporting finish to our memories of our 
HMS years. Indeed, it proved to be a 
cozy, quiet cove in which to put down 
anchor and remember. We had a 
delightful evening, with the environ- 
ment full of reminiscences. 

On Alumni Day, at the end of an 
excellent program, our mass fled to the 
airport or home, leaving only one of us 
for the picture. All who came were 
glad to have joined old friends, as the 
morbidity and mortality of the next 
three years make a 65th reunion 
unlikely! 

Thomas A. IVarthin '5^ 



60TH 



Hi. ^ 




The 60TH REUNION of the Class of 
1936 was blessed vdth good weather, 
stimulating exposure to advances in 
medicine, and cordial fellowship. Of 
the 52 living members, 16 returned, 
two traveling from the far West — Joe 
Ross and Ed Candon. 

At a reception in the Lahey Room 
of the Countway Library, Dean 
Federman '53 described differences in 
the present day school, i.e., the equal 
numbers of women in the first-year 
class. 

On Friday socializing resumed viath 
the Alumni Day lunch on the 



Quadrangle. The class gathered that 
evening at the tasteful, secluded 
Wellesley home of Jane and Sarg 
Cheever for an elegant catered dinner. 
The presence of Ethel Ulfelder and 
Mary Eliza McDaniel added luster to 
the occasion. 

The next morning under hazy skies 
we sailed the Charles River for an hour 
with the skipper's commentary on the 
sights ashore. Then it was on to a lim- 
cheon given by Elizabeth and Will 
Sweet in the Loeb House in Harvard 
Yard, a manorial setting, erstwhile 
home for the presidents of Harvard. 



The Alumni Office provided bus 
transportation for these functions, but 
on two occasions "getting to the bus in 
time" proved too difficult for other- 
wise solid examples of graceful aging. 
Arthur Baldwin 'j5 



Autumn 1996 



43 



55TH 




Good weather, good spirits and 
mellow bonhomie characterized our 
reunion. Twenty-six members and 20 
spouses of the Class of 194 1 attended a 
marathon: Thursday reception at the 



Countway Library, Friday Alumni Day 
exercises on the Quadrangle, followed 
by lunch, Friday dinner at the Harvard 
Club, culminating with a fine clam- 
bake at the Culvers' house in Lincoln 



on Saturday. 

Our pre-reunion questionnaire 
asked for the names of teachers fondly 
remembered. This produced an 
astounding total of 83 names. We 
recalled them in a long and uproarious 
series of anecdotes, enlivened by song 
(Hawn, Kanwit), and especially Joe 
Foley's seemingly endless store of 
wonderful people and events. We felt 
lucky indeed to have known all these 
men, most of whom received little or 
no pay for teaching, but who neverthe- 
less made important contributions to 
medicine. We felt that despite war and 
financial problems, we were glad to be 
who we are and active during the 
golden age of American medicine. 

Curtis Prout '^i 



5OTH \ 




Sixty-three stalwarts (61 plus or 
minus 2 percent) with or without wives 
or friends attended and enjoyed seeing 
old friends in familiar surroundings. 
Since leaving the Quadrangle, we have 
practiced and researched from Maine 
to San Diego, from Seattle to Miami, 
and from Great Britain to Pakistan. In 
so doing, we have collected two Nobel 
Prizes in Medicine, have been deans 
and professors, have served as major 
medical administrators and have prac- 



ticed as superspecialists, subspecialists 
and generalists. In other words, we 
have contributed to the well being of 
mankind. 

The festivities opened Thursday 
with a reception in the Common 
Room of Vanderbilt Hall, which 
looked the same except for John's 
absence behind the desk. On Friday 
there was an alumni symposium in the 
morning. A class picture was taken at 
noon and dinner took place in the 



evening in the Courtyard Cafe in the 
new Alpert Research Building of the 
Quadrangle. The company was excel- 
lent as were the food and drink. After 
dinner there was no lack of speakers 
from our class who chose subjects 
from "What HMS Meant to Me" to 
"How to Fix the World," each hmited 
to two minutes by an uncompromising 
George Richardson. On Saturday we 
gathered at George and Becky 
Richardson's house in Nahant for a 
Down East clambake. 

The weather cooperated beautifully 
for all these events. The alumni office 
seemed happy with our $78,000 con- 
tribution, and so we scored a perfect 
10 in the dash, weight Ufting and the 
marathon. 

John W. Braasch '^6 



44 



Harvard Medical Alumni Bulletin 



45TH 




The Class of 195 i gathered in fine 
weather for its 45 th reunion. Ruth and 
Herb Weiss hosted supper on 
Wednesday for 53 class members and 
their spouses. Gerry and Ruth Foster 
opened their home for a buffet dinner 
for 67 on Thursday evening. 

Friday's program on ethics under 
managed care produced numerous 
questions and comments from 
alumni/ae of all ages and styles of prac- 
tice. The Weekapaug Inn weekend pro- 
vided ample opportunities to reminisce, 
to consider pros and cons of retirement, 
and to attempt to make sense of the 
rapidly changing health care field. 
Many expressed a hope for a big gather- 
ing at our 50th reunion in 2001. 

Ellen Bell's J 



4OTH 




The 40TH REUNION of the Class of 
1956 was a huge success. The cama- 
raderie, respect and friendship that the 
members of the class have for each 
other produced a record participation 
for a 40th reunion. 

The reunion began with a buffet 
reception at the home of Barbara and 
Joel Alpert, which was attended by 86 
classmates and spouses. The informal 
setting, combined with superb food 
and beverages, provided an excellent 
atmosphere for the members of the 
class to rekindle memories. The long- 
standing warmth among the members 
of the class was immediately evident. 



The following afternoon, 60 people 
had a unique re-introduction to 
Boston on a Duck Tour. This 
amphibious vehicle traveled not only 
through the streets of Boston, but also 
into the Charles River. This was fol- 
lowed by a formal dinner at the Bay 
Tower Room attended by 102 guests. 
Classmates attended a busy Alumni 
Day, pausing to join in tribute to Cliff 
Barger, our beloved instructor in phys- 
iology. Following the Alumni Day 
program, the class regrouped at the 
Chatham Bars Inn on Cape Cod. The 
renovated inn was elegant and the 
weather sparkled with a large fog bank 



remaining appropriately offshore. 
Fifty-nine of us had the opportunity to 
further enjoy the long-standing rela- 
tionships among the members of HMS 
'56. The clambake on Friday night and 
elegant dinner on Saturday were oppor- 
tunities to pause and toast. Our exuber- 
ant spirits stood out, perhaps to the 
amusement of others in the dining 
room. Following dinner both evenings, 
we were treated to the artistry of Dick 
Sogg at the piano. The voices of HMS 
'56 and our spouses and a few acquired 
friends from the dining room joined 
Dick's special renditions of popular 
tunes as well as excerpts from the 1956 
second- and fourth-year shows, ending 
with a rousing rendition of 
"Gaudeamus." 

In the years between the 35th and 
40th reunion, our class has held two 
mini-reunions in New England, both 
attended by classmates living as far away 
as California, together with their 
spouses or significant others. We have 
been friends for a long time and look 
forward to our future reunions. 
Whatever routes we have pursued, 
whether still active (many) or retired (a 
few), we know that HMS has provided us 
with the best possible roads to travel. 

Stefan Schatzki '^6 and Joel Alpert '5^ 



Autumn i 996 



45 



35TH 




The 35TH REUNION of the Class of 
1 96 1 was truly one of the most fun- 
filled, enjoyable and flawless ever. I say 
this with all modesty because, as 
reunion co-chair, I had little to do 
with this perfectly wonderful outcome. 
It was largely due to cooperative 
weather, great attendance, wonderful 
accommodations and good luck! 
There was also the not inconsiderable 
hospitality of my co-chair, Tenley 
Albright, and her husband, Jerry 



Blakeley, who opened their Oyster 
Harbors home and all its amenities to 
classmates and their spouses for the 
entire day and evening on Saturday, 
June 8. 

But I get ahead of myself. The 
activities began on Thursday evening, 
when Ren and Peggy Zimmerman 
hosted us in their wonderful home for 
a buffet reception. The food was eth- 
nic (Brazilian) and delicious, the 
indoor and outdoor settings lovely. 



and as usual, everyone who attended 
greeted everyone else as if we had just 
seen one another yesterday. On Friday 
morning there was a great turnout for 
the Alumni Day activities and the 
usual chaos and conviviality at the tak- 
ing of the class picture. 

On Friday evening, 70 plus class- 
mates and spouses attended a wonder- 
ful dinner at The Country Club in 
Brookline. It was a perfect setting, 
with terrific service, deHcious hors 
d'oeuvres, a wonderful main course, 
and an ambulatory dessert and coffee 
hour. Between dinner and dessert we 
were entertained by Peter Liebert's 
now-traditional slide show of nostalgic 
photos from our medical school days 
and prior reunions. 

We were also privileged to have as 
our guests Professor George E. 
Erikson (anatomy) and his wife. 
Professor Erikson gave a short presen- 
tation about the Erikson Biographical 
Institute, which houses an invaluable 
and enormous database of information 
about thousands of Harvard graduates, 
their appointments, their honors and 



3OTH 




The Class of 1966's 30TH reunion 
began Thursday evening with a cock- 
tail buffet at the gracious home of gra- 
cious hosts — Jensie and Bill Shipley in 
Chestnut Hill. The large turnout of 



docs, spouses, kids and significant oth- 
ers combined with perfect weather to 
start off a fine reimion. Friday, Alumni 
Day, began with a symposium on med- 
ical ethics in a managed care era which 



provoked many questions and much 
thought. Luncheon was fine, the 
weather was perfect, and the class 
photo proves that many of our fine 
class can follow simple instructions by 
remembering when to show up. Then 
on to the Stage Neck Inn in York 
Harbor, Maine where some started 
right in with power naps while others 
walked along the breathtaking coastal 
paths. The really serious ones began 
shopping at Freeport and Kittery. 

Jay Kaufman, as usual, was a mas- 
terful M.C. Friday evening. Before 
dinner he asked for a quiet moment 
and read the names of the seven of us 
who have died since 1966. Jay passed 
the microphone to members of the 
class in between courses of a fine meal 
complemented by some very good 
wine. (You can be sure that the wine 



46 



Harvard Medical Alumni Bulletin 



professional histories. He has just 
added information on almost loo of 
the members of the Class of 196 1. 

Our final day of reunion activities 
began in the morning and did not end 
imtil mid evening. A bus and assorted 
other modes of transportation brought 
about 50 classmates and spouses to 
Oyster Harbors on Cape Cod, the 
vacation home of Tenley and Jerry 
Blakeley. Here we had muffins and 
coffee, lunch and dinner, all delicious 
and beautifully served. Tennis, bad- 
minton, swimming, boating, ping 
pong, beach or poolside lounging, 
walking and assorted other activities 
were available. Refreshments were 
served throughout the day and every- 
one had an extended opportunity for 
conversation, socialization and relax- 
ation. Rumor has it that the only sour 
note was struck when the bus got a lit- 
tle lost in the heavy fog on the way 
back from the Blakeleys. 

A final word: We missed those of 
you who could not be there. Even 
though we reunite only every five 
years, it seems as if we have a better 




time together, get to know one 
another better and feel closer to each 
other each time we do. To all of you 
who thanked me verbally and in writ- 
ing for my efforts to help prepare for 
the reunion, let me add that it is a 
labor of love and well worth the small 
amount of time and energy involved. 
My thanks to Nora Nercessian and her 



Boston Herald photo 
announces that women 
invade the Deanery, 1958. 

Staff for all their help with the arrange- 
ments and to the rest of the reunion 
committee for their efforts. And most 
of all, my thanks to Tenley, the best of 
co-chairs. I'm already looking forward 
to 2001! 

Muriel Sugarman '61 




was good because Gil Grave asked for 
the label). The spontaneous remarks 
from classmates were thoughtful, 
anguished, encouraging, upbeat, ten- 
der and revealing. Many expressed 
angst about the changes wrought by 
managed care. The Marmors and the 
Fletchers demonstrated once again 
that behind every succesful HMS gradu- 
ate there is a lovely supportive hus- 
band. When things got too rowdy and 
raucous, Jay turned to HMS's favorite 
man of the cloth, Ned Cassem, SJ, 
hoping for a more sober tone. But all 
he got was more humor and outra- 
geous remarks. 

Gerlinde Bowen said to some at 
tennis Saturday, "I read the In 
Memoriam section in the reunion 
book. What a shame that some of you 
people have taken your own life. 



Imagine. Why don't you tell your 
classmates that if they ever feel really 
bad they should come up to 
Shelburne, Vermont and stay with 
Chuck and me. We'll take you sailing 
on the lake and you'll be fine." Linda 
Stubblefield spoke up on Saturday 
evening. "I've known many of you for 
years and I've made new friends this 
weekend. I've seen what effort, sacri- 
fice and caring you've put into your 
work over these years. I want you doc- 
tors to know I'm so proud of you!" 

We left on Sunday going back to 
separate careers, feeling good. Some 
thought we shouldn't wait five years to 
see each other again. 

Richard Hannah '66 



Digging out of a snow storm: D. Michael Crick, 
Tom Gutheil and Alfred Goldberg 



Autumn i 996 



47 



25TH 




The 25TH REUNION of the Class of 
'71 was not only a fabulous success, 
but the best ever. Alex Murray 
Harrison's cocktail party was packed. 
The dinner at the MEG at HMS was ter- 
rific and the harbor cruise was a plea- 
surable end to the events of the week. 
The highlight of the reunion was hear- 



ing our own classmates deliver out- 
standing lectures at our class sympo- 
sium. Stu Orkin, Bonnie Pagon and 
John Curd spoke on the new genetics. 
David Bear, David Spiegel and Mark 
Rosenberg spoke on the impact of vio- 
lence; and Alex Murray Harrison, Jon 
Jacobs and Jesse Sigelman spoke on 



personal odysseys. (I bet people are 
still sohciting financial advice from 
Jesse!) 

For those who couldn't attend the 
reunion or hear the results of the 
anonymous questionnaire, here is a 
thumbnail summary: 92 percent of our 
class live in our own houses with four 
percent each in condos and rental 
units. Twenty-nine percent own more 
than one residence; 27 percent live in 
the city; 58 percent live in the suburbs 
and 1 5 percent in the country. Seven 
percent of the respondents disclose a 
household income of 50 to 100 thou- 
sand; 36 percent between 100 and 200 
thousand; 33 percent between 200 and 
400 thousand; 19 percent between 400 
and 600 thousand, and 4 percent over 
600 thousand. 

Sixty-nine percent have stayed mar- 
ried to their original spouse for a mean 
of 22.5 years; 24 percent are on their 
second marriage; 5 percent are cur- 



20TH 




Out-of-town guests were wel- 
GOMED Thursday evening by Tom 
Aretz, who organized a get-together 
with cocktails and hors d'oeuvres at his 
house. Tom later commented that as a 
class, we are very light drinkers. 

For many of us though, our first 
encounter in five years occurred on the 
steps of Building A, when we assem- 
bled for our class photograph on 



48 



Friday. Fortunately, most of us recog- 
nized each other immediately. The 
weather was sunny and pleasant, and 
the beautiful and nostalgic surround- 
ings helped catalyze our reminiscences 
fi"om 20 years ago and our "catching 
up" with each other. 

That evening, we had dinner at the 
newly renovated Top of the Hub. The 
highlight was Marvin J. Bittner's ren- 

Harvard Medical Alumni Bulletin 



dition of "The Seven Warning 
Signals," a speech he had given and 
directed toward Dean Robert Ebert 20 
years ago. For the occasion of our 
reunion, Marvin composed another 
verse (the "Second of the Seven 
Warning Signals"). He promised to 
add verses incrementally every five 
years. This will provide us with the 
impetus to remain healthy. After din- 
ner, we also remembered those col- 
leagues who have passed away (Jay 
Knighton, Jack Schiff and Lewis van 
Hoosear). 

The weekend finale was an 
impromptu picnic that was graciously 
hosted by Fred and Joan Mansfield in 
Lincoln. The weather continued to be 
perfect and we had a chance to meet 
the children of the class, some of 
whom will be in the next generation of 
HMSers. Finally, of course, there were 
planes to catch and other obligations 
to meet. We resolved to stay in closer 
touch with each other over the next 
five years, as we begin now to plan our 
gala 2 5th-year reunion. 

Saniuel Z. Goldhaber '7^ 



rently divorced. Sixty-nine percent are 
in excellent health; 24 percent have 
minor health problems; 3 percent have 
signs of serious problems and i per- 
cent have serious health problems. 
Sixty-seven percent weigh more than 
in school (mean+i6 lbs); 13 percent 
less (mean=i2 lbs) and 20 percent the 
same. Forty-one percent describe 
themselves as liberal; 32 percent con- 
servative, with the remainder neither. 
Fifty-eight percent voted for Clinton; 
32 percent for Bush and the rest Perot. 
Fifty-one percent favor a single payer 
health system; 1 3 percent favor man- 
aged care; 5 percent favor status quo 
and the rest, none of the above. We 
appear to be very happy in both our 
professional and personal lives, though 
a significant fraction have wound up in 
different positions than we thought we 
would be. Seventy-three percent of us 
would go into medicine today but only 
49 percent would encourage our chil- 



dren to do so. 

It was really fun seeing all the class- 
mates who returned for the 25 th 
reunion. Congratulations to Ann 
Stark, Alex Murray Harrison, Frank 



Berson, Joel Schwartz, Craig 
Donaldson and Bill and Cyndi Kettyle 
for their hard work in putting together 
this event. 

Mark Goldman '71 




March on Washington 



I5TH 




30 people to enjoy an amazing view of 
the harbor as the sun went down. Most 
people recognized each other and we 
were delighted to see classmates from 
Ohio, Pennsylvania and Florida. The 
conversations continued in the leafy 
backyard of Judy Lieberman's home 
on Saturday afternoon, when 20 class- 
mates and many children added to the 
fun. We look forward to more gray 
hair and more children at the 20th 
reunion. 

Ilonna Rimm '81 



The 1 5TH REUNION of the Class of 
1 98 1 had the shape of an hourglass. At 
the top, we had the opportunity to 
read about the activities of 50 of our 
classmates in the reunion book. 
Michael Payne did a superb job com- 
piling the answers to two question- 
naires and editing the tome. I was 
pleased to learn that the survey 
respondents from our class have had 



an average of 2.22 children. 

After the book arrived, I was look- 
ing forward to seeing old friends in the 
class picture, which turned out to be 
the narrow waist of the hourglass. The 
picture call resulted in exactly two 
people on the steps of Building A, Carl 
Schwartz and I. 

The Friday night dinner at the Bay 
Tower Room was an opportunity for 



Autumn i 996 



49 



lOTH 




The Class of 1986 had a wonderful 
loth reunion. There was a spectacular 
turnout, with aliimni returning from all 
corners of the country. 

On June 7 a dinner was held at 
Peking Gardens in Lexington where a 
number of 'awards' were given out, 
including the long distance award to 
Linda Leum, who came from 
Washington state; although David 
Swerdlow claimed to have just gotten 
off a plane from Rio de Janeiro, Brazil. 
The next day a picnic for alumni and 
children was held at the home of Mark 
Hughes and Delia Sang. There was a 
spectacular turnout with 55 adults and 
3 3 children (thank goodness for the jun- 
gle gym!). 

A special thanks for the reunion suc- 
cess must go to the committee consist- 
ing (besides myself) of John Ayanian, 
Ming Hui Chen, David Cohen and Ken 
Kay. We look forward to the 1 5th 
retmion! 

Mark Hughes '86 



5TH 




The Class of 199 i gathered at 
the Cornucopia-on-the-Wharf restau- 
rant on Friday, June 1 for a lovely din- 
ner overlooking Boston Harbor. The 
next day, the class met for a terrific 
picnic at Auburndale Park in Newton. 
We were fortunate to have a large 
number (about 2 5) of alumni in atten- 
dance. Sally Holtzman traveled from 



Arizona for the occasion. Kathan 
(Hickey) Vollrath came all the way 
from California as did Lise (Bettinger) 
Rak, along with her husband, Ed, and 
their daughter, Annie. Mark and Emily 
Ceisler-Blitzer came up from New 
York. Alumni from Boston included 
Chris Peckins and Susan Abookire 
(with children Sylvie and Robert), 



Beth Beigelson, Mary Barton, Alison 
May, Monika Woods (with fiancee 
Rohan), David Greenes, Josh 
Gundersheimer, Inna (Goldberg) Gazit 
(with husband Yuval), Data Lee and 
Jordan Smaller, Stephanie Seminara 
and Brian Labow '93, Bruce Wintman 
and Jorma Gaberman '92, Lee 
Schwamm and Lisa Leffert, Zoher 
Ghogawala, Alik Farber, Roberto 
Eriedlander (with friend Eugenia) and 
Jane Liebschutz (with friend Gary). 

The reunion was a lot of fun. It was 
a chance to remember and laugh about 
our times at HMS. Also, it was an oppor- 
tunity to share our various approaches 
to navigating today's medical world and 
our hopes for the future. Stay tuned — 
our next revmion is only five years away! 

Zoher Ghogawala 'p i 



50 



Harvard Medical Alumni Bulletin 



An Alumnus Travels 
the New Pathway 



by Harry S. Jacob 



My fellow academicians who 
suffer from the emerging insight that 
academic medicine is in a freefall, a 
therapeutic suggestion: consider a mini 
sabbatical trekking the New Pathway 
as a visiting HMS scholar. In the winter 
of 1995 I did a three-month stint 
among the Longwood high-rises and 
enjoyed my visit enormously. My first 
day back at HMS found me circling 
enormous cranes and even larger exca- 
vations for new building sites while 
looking for an old friend, Vanderbilt 
Hall. I can report happily that it still 
stands. 

I came to tutor HMS students in the 
New Pathway "Human Systems" cur- 
riculum and am now devoted to this 
pedagogical model. Devoted, in spite 
of the astonishment registered by a 
close friend and distinguished HMS 
hematologist, who found it unbeliev- 
able that I would actually volunteer to 
be involved in this "touchy-feely" (sic) 
teaching endeavor. 

In fact, the closeness that one 
achieves with a small group of bright, 
inquisitive tutees has a therapeutic 
effect. I was suffering from far- 
advanced Chronic Frustration 
Syndrome, a malady endemic to acad- 
emic medical centers today. I do not 
think I have been to a single faculty 
meeting in the last five years that did 
not speak solely to fiscal issues. Those 
who seem to give a damn about stu- 
dents in my own institution are few 
and dwindling in lock-step with 
patient collections. In addition, I have 



not heard anything about how our fac- 
ulty might develop problem-solving 
skills in our student progeny, although 
it should be obvious that such skills are 
fundamental to our professional call- 
ing. 

How refreshing then to learn of the 
continued efforts at HMS to create new 
models for teaching. "Touchy feely" 
or whatever, I wanted to see for myself 
how the New Pathway and its nondi- 
rective tutorials work. 

I did not come to tutorial teaching 
as a novice. My undergraduate back- 
ground was at a small liberal arts insti- 
tution. Reed College, where small 
group conferences were the norm. 
Forty years ago we were swept up in 
the then radical idea that students, 
after reading source literature, could 
create their own "knowledge" by spec- 
ulating about the material. Anything 
was worth debating if it could be 
rationally defended. Professors guided 
gently but generally let a lot of 
"Brownian motion" oscillate before 
hauling in the rhetorical reins. I am 
certain that my later modest successes 
as clinician and scientist grew directly 
from this pedagogical method. 

I am willing to wager that New 
Pathway students too will be more 
successful lifelong-learners and cre- 
ative thinkers than traditionally taught 
students. (Unfortunately the bet won't 
be payable until analysis of the pioneer 
students is made at least 20 years from 
now!). 

At HMS I initially "audited" a week 



of tutorials with my soon-to-be ten 
students. They were dissecting a case 
of a middle-aged woman with septal 
defect under the watchful eye of their 
cardiology/pulmonary tutor. Each case 
is discussed in two, two-hour tutorials, 
separated by three days. 

The students are ill prepared (on 
purpose) for the first day session and 
quickly run into information gaps. 
This is one of the strategies that drives 
the engine of learning in this model, 
specifically, the need to know acts as a 
strong prod for the student to gather 
information prior to the next and ulti- 
mate tutorial session. They do litera- 
ture searches and, more importandy, 
share learning tasks with each other. 
The tutorials foster true team learn- 
ing, with all group members feeling a 
responsibility to bring information 
back to their colleagues. 

What a difference from my HMS 
days 3 5 years ago when competition 
for house officerships seemed to sur- 
face and divide students from the very 
first day of matriculation. I felt none of 
this unpleasantness in my hematology 
group over the five weeks of our time 
together. Instead, great humor, colle- 
giality and enthusiastic speculation 
graced our sessions. 

The team learning phenomenon is 
remarkably enhanced by the lovely 
architecture of the Medical Education 
Center (old Building E). A central 
massive atrium — which provides the 
only unimpeded sunlight in the area — 
attracts heliotropic students and gre- 



AuTUMN 1 996 



51 



garious facult\' members, particularly 
at mid day. It became apparent that 
conimdra emanating from that day's 
tutorial case were being loudly 
thrashed out by students munching 
sandwiches. I rarely got through the 
tables without being hailed with a 
"Hey Harr\'" by one or more students 
wanting to try out a hj^othesis about 
the week's case. 

I decided early on that our group 
was gifted in their ability to speculate 
and create, so I encouraged digression 
from the case at hand, challenging my 
students to develop mechanisms of dis- 
ease or therapy that have not been pre- 
viously described. For example, one of 
the students provided a rational model 
for the mysterious long-term "toler- 
ance" that some immune thrombocy- 
topenic purpura patients develop 
following brief plasmapheresis over 
immunosorbent columns. When I told 
him that his ideas had merit, he made 
copies of this formulation and distrib- 
uted them to his fellow students — a 
moving example of the team learning 
that I found so attractive. 

I was constantly astonished at how 
often my group would founder in their 
case discussions exactly where knowl- 
edge is, in fact, shaky, or where dogma 
deserves to be challenged. From these 
impasses often came first-rate specula- 
tions by the students. In fact, my labo- 
ratory in Minnesota is currently 
following up on a suggestion concern- 
ing the possible sensor for thrombo- 
protein secretion, arguably one of the 
hottest current mysteries in hematol- 
ogy- 

Admittedly, the contemplative 
exercises typical of the New Pathway 
take time, both for the student and 
faculty person; but I submit that this is 
a marvelous investment of time for 
both. Contact with students has re- 
energized me. 

So here is my recipe for a successful 
visit back to the Quadrangle: four to 
six weeks of tutoring in the second- 
year curriculum; vigorously stir in 
some morning reports, morbidity and 
mortality conferences, rounds and the 



like; finish with palate-clearing subspe- 
cialty conferences at the Harvard hos- 
pitals, and enjoy your heady stew. In 
addition, life with one's spouse is sure 
to thrive with Boston/Cambridge 
bistro hopping, museum meandering 
and symphony crawling. Catching up 
with old friends who stuck it out in 
Boston is another therapeutic benefit. 
With luck, you will brag as I do that 
your students regularly nipped at your 
ankles but never broke skin. ^ 

Harry S. Jacob '^8 is professor and vice 
chairman of the Department of Internal 
Medicine and head of the Division of 
Hematology at University of Minnesota 
Medical School. Any alumnus interested 
in doing something similar should contact 
Dean Federman at 6^77-452-1.^5)7 or via 
email at dfeder@'warren.med.harvard. 



52 



Harvard Medical Alumni Bulletin 


















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